Recast  from  Lectures  Delivered  at  Rash  Medical 

CoIIegfe,  in  Affiliation  with  the 

University  of  Chicago 


NORMAN  BRIDGE,  A.M.,  M.D. 

Emeritus  Professor  of  Medicine  in   Rush  Medical  College ;   Member  of  tlie 

Association  of  American  Physicians ;    Member  of  the  American 

Climatolcgical  Association  ;   Corresponding  Member 

of  the  Wisconsin  Academy  of   Sciences, 

Arts,  and  Letters. 


Philadelphia,  New  YorK,  London     ( 

W.  B.  SAUNDERS  ^  COMPANY 

1903 


i   ?0 


Copyright,  1903,  by  W.  B.  Saunders  &  Company. 
Registered  at  Stationers'  Hall,  London,  England. 


PREFACE 

The  substance  of  the  lectures  on  Medical  Tuber- 
culosis delivered  by  the  author  in  Rush  Medical  Col- 
lege during  the  past  three  years  is  embodied  in  this 
book.  The  form  of  the  work  has  been  somewhat 
changed ;  some  more  detail  has  been  introduced,  in 
statistical  matter  and  otherwise,  and  some  few  things 
uttered  in  the  necessity  of  lecture-room  discussion 
have  been  omitted. 

The  treatment  of  the  subject  is  not,  and  with  the 
size  of  the  volume  could  not  be,  exhaustive;  but  a 
correct  statement  of  the  science  of  the  disease  has 
been  attempted,  and  at  the  same  time  the  practical 
side  of  the  care  and  management  of  those  sick  with 
its  different  non-surgical  forms,  and  for  the  protec- 
tion of  the  community  from  the  spread  of  the  dis- 
ease, has  been  emphasized. 

This  latter  phase  of  the  subject  has  heretofore 
been  neglected  by  many  of  the  profession,  to  the  ca- 
lamity of  both  the  sick  and  the.  well.  The  old  and 
inadef|uate  way  of  regarding  consumi)tives  and  deal- 
ing with  their  diseases  was  due  partly  to  habit  and 
partly  to  the  gloom  with  which  such  invalidism  was 
surrounded.  Rut  in  this  day  of  better  hope  for  the 
victims  of  this  amazing  disease,  and  better  knowl- 
edge of  how  to  prevent  it.  a  new  science  and  a  new 

3 


4  Preface 

gospel  need  to  be  taught,  to  the  end  that  both  the 
profession  and  the  pubhc  may  be  aroused  to  their 
duty  and  opportunities. 

This  booi<  is  submitted  in  the  hope  that  it  may 
help,  if  only  in  a  small  way,  toward  this  consumma- 
tion. 

The  author  has  great  pleasure  in  expressing  his 
indebtedness  to  Dr.  Henry  B.  Stehman  and  Dr. 
Stanley  P.  Black  for  generous  and  critical  assistance 
in  the  prei)aration  of  the  volume. 

Los    Angeles,    California, 

March,  1903. 


CONTENTS. 


CHAPTER    I.  PAGE 

The  Bacillus  Tuberculosis 9 

CHAPTER    II. 
The  Tuberculous  Process 27 

CHAPTER    III. 
Forms  of  Tuberculosis 39 

CHAPTER    IV. 
Pathology  of  Tuberculosis 51 

CHAPTER   V. 
Etiology  of  Tuberculosis 69 

CHAPTER    VI. 
Symptoms  of  Tuberculosis 79 

CHAPTER    VII. 
Physical  Signs  ok  Tuberculosis 100 

CHAPTER    VHI. 
Diagnosis  of  Tuberculosis 120 

CHAPTER    IX. 
Prognosis  of  Tuberculosis 143 

CHAPTER   X. 
Prophylaxis  ok  Tuberculosis 161 

CHAPTER   XT. 

Treatment,  General  Principles 177 

6 


6  Contents 

CHAPTER    XII.  PAGR 

Treatment,  Hygienic 192 

CHAPTER    XIII. 
Management  ok  the  Diseased  Lung 214 

CHAPTER   XIV. 
Treatment,  Climatic 230 

CHAPTER   XV. 
Treatment,  Medicinal  and  Local 248 

CHAPTER   XVI. 
Treatment,  Medicinal  (Continued) 262 

CHAPTER   XVII. 
Special  Treatments 278 

CHAPTER   XVIII. 
Sanatoria  for  Tuberculosis 286 


Index 297 


TUBERCULOSIS 


TUBERCULOSIS 


CHAPTER   I 

THE  BACILLUS   TUBERCULOSIS 

Tuberculosis  is  the  most  frequent  and  destruc- 
tive disease  of  man.  It  attacks  many  organs  and 
appears  in  many  forms, — forms  that  have  been  re- 
garded as  distinct  diseases  and  known  by  a  variety 
of  names ;  and  it  destroys  probably  at  least  one- 
ninth  of  all  the  white  races.  It  is  now  known  to 
be  due  to  the  growth  in  the  tissues  of  the  tubercle 
bacillus,  discovered  by  Koch  in  1882,  and  no  tuber- 
culous lesion  exists  without  the  presence  of  this  or- 
ganism or  of  the  direct  influence  of  its  growth 
and   development. 

The  bacillus  tuberculosis  is  only  one  of  many 
microbes,  pathogenic  and  non-pathogenic,  invading 
the  human  body.  Most  of  the  micro-organisms 
are  received  into  the  body  by  inspired  air  and  by 
food  and  drink,  and  the  number  acquired  is  enor- 
mous. In  different  atmospheres  the  number  of  or- 
ganisms inhaled  by  an  adult  person  varies  from 
probably   half  a    dozen    to   several    lumdrcd    every 

9 


lO 


Tuberculosis 


minute  of  life.  Tubercle  bacilli  are  acquired  some- 
times through  direct  contact  with  abrasions  of  the 
skin,  wounds  and  orificial  mucous  membranes,  as 
well  as  through  the  respiratory  and  digestive  organs. 
Koch's  bacillus  is  a  colorless,  aerobic,  rod-like 
organism,  often  slightly  curved,  probably  non-motile 


Fig   I. — Bacillus  tuberculosis  in   sputum,   stained  with  carbol- 
fuchsin  and  aqueous  methylene-blue.     X^^oo- 

and  unflagellate,  of  variable  length  to  the  limit  of 
3.5  or  4  mikrons,  or  three-quarters  of  the  diameter 
of  an  average  red  lilood-corpuscle,  and  al^out  one- 
tenth  as  broad  (Fig.  i).  It  differs  in  form  and 
size  somewhat,  and  may  be  branched  or  nodulated, 


The  Bacillus  Tuberculosis  ii 

all  depending  on  the  circumstances  under  which  it 
has  grown  and  possibly  on  the  bodies  through  which 
its  generations  have  passed.  The  branched  or 
nodulated  forms  are  rarely  found  save  as  the  result 
of  experimental  growth.  When  stained  red,  it 
looks,  under  the  microscope,  not  unlike  a  minute 
cutting  of  attenuated  red  hair.  Some  believe  that 
the  different  sizes  and  shapes  of  the  bacilli  differ 
in  their  infecting  powers  to  the  system ;  the  shorter 
and  thicker  specimens,  which  take  the  stain  best, 
being  the  product  of  the  severer  cases.'  If  this 
is  true,  it  would  argue  that  these  forms  are  fewer 
generations  removed  from  their  origin  in  bovine 
bacilli. 

The  bacillus  is  peculiar  in  containing  various  oily 
substances,  thought  by  some  to  reside  in  a  (rather 
supposititious)  firm  surrounding  wall,  and  giving 
different  appearances  when  treated  by  various  sub- 
stances, especially  alcohol  and  ether.  Cold  alcohol 
extracts  8  per  cent,  of  the  total  weight  of  the 
bacilli,  and  becomes  very  red  by  the  change  of  a 
form  of  chromogen  in  the  presence  of  alcohol  and 
oxygen.  From  8  to  20  per  cent,  or  more  by  weight 
is  extracted  by  a  mixture  of  alcohol  and  ether, 
depending  somewhat  on  the  age  of  the  culture. 
Ruppel  has  separated  from  tubercle  bacilli  a  new 
ptomain  w^hich  he  has  named  tuberkulosamine.     He 

'Dr.  Henry  Scwall.     The  Medical  News,  March  16,   1901. 


12  Tul)erciilosis 

believes  it  to  exist   in   the  organisms  in  combina- 
tion with  nucleinic  acid. 

The  tubercle  bacillus  stains  with  difficulty,  re- 
quiring the  aid  of  a  mordant  like  carbolic  acid, 
anilin,  or  an  alkali,  but  when  once  stained,  it  re- 
tains its  color  more  tenaciously  than  most  other 
organisms,  and  more  than  the  tissues  of  the  body, 
when  treated  by  decolorizing  agents.  This  power 
undoubtedly  resides  in  the  fatty  matters  of  the 
bacillus. 

Koch  has  found  that  -the  fatty  substances  which 
the  bacilli  contain  include  two  unsaturated  fatty 
acids,  one  of  which  is  soluble  in  dilute  alcohol, 
while  the  other  is  proof  against  everything  but 
boiling  alcohol  and  ether.  Therefore  it  must  be 
lliat  the  former  is  removed  by  the  staining  fluid 
which  contains  alcohol,  and  that  the  latter  remains 
after  the  destaining,  and  therefore  is  probal)ly  the 
substance  that  fixes  the  stain.  It  is  this  staining 
proi)erty  that  led  to  the  discovery  of  the  bacillus. 
It  was  at  first  supposed  that  no  other  bacillus  which 
more  or  less  resembles  it  had  this  peculiarity,  but 
several  possess  it  in  varying  degrees,  especially  the 
lepra  and  smegma  bacilli ;  while  those  of  butter, 
hay,  and  grass  have  similar  tinctorial  qualities. 
The  smegma  bacilli,  unlike  tubercle  bacilli,  are  de- 
colorized by  thorough  treatment  with  absolute  al- 
cohol.^ Several  different  organisms  are  more  acid- 
^Dr.  George  Rlumer,  Bender  Laboratory,  Albany,  N.  Y. 


The  Bacillus  Tuberculosis  13 

proof  than  the  Koch  bacillus.  The  peculiar  staining 
property  of  these  bacilli  is  due  to  the  fat  they  con- 
tain or  which  surrounds  them,  acquired  probably 
from  the  substances  in  which  they  grow.  Remove 
the  fat  by  alkalis  and  this  property  is  gone. 

The  bacillus  grows  in  various  artificial  media, 
but,  as  compared  with  many  other  organisms,  it 
is  difficult  to  propagate.  The  temperature  that 
most  favors  its  growth  is  about  37.5^  C.  (99.5° 
F.),  but  it  does  grow  at  a  temperature  as  low  as 
60°  F.  under  some  circumstances;  its  development 
is  retarded  by  any  considerable  variation  from  this 
point.  It  grows  fairly  well  in  blood-serum,  acid- 
ulated agar  agar  with  glycerin,  bouillon  with  gly- 
cerin, and  e\en  on  cooked  potato.  It  has  been 
grown  on  filter-paper  and  on  common  wall-paper, 
when  moistened  l)y  human  l)reatli  or  by  aqueous 
vapor  emanating  from  damp  soil. 

The  bacillus  multi])lies  by  division, —  whether  by 
manifold  division  into  spores  remains  to  be  shown, 
and  is  unlikely.  Many  individual  bacilli,  presum- 
ably the  older  ones,  are  seen  under  the  microscope 
to  have  the  ai)pearance  of  a  string  of  beads,  as 
though  just  undergoing  division  into  spores;  but 
it  is  alleged  that  the  spaces  between  the  red  dots 
are  vacuoles,  or  points  in  the  walls  or  substance  of 
the  bacillus  that  either  have  not  taken  the  stain 
or   have   relinquished,   it   more   quickly   to   the   de- 


14  Tuberculosis 

staining  fluid,  and  that  the  appearance  is  no  proof 
of  spores. 

This  bacihus  is  found  in  the  bodies  of  various 
lower  animals,  where  it  produces  many  of  the  phe- 
nomena seen  in  the  human  subject.  Monkeys,  cat- 
tle, sheep,  goats,  swine,  horses,  chickens,  cats,  dogs, 
rats,  rabbits,  and  guinea  pigs  (even  fish  fed  on 
tuberculous  sputa),  and  doubtless  many  other  ani- 
mals, are  thus  afflicted  with  tuberculosis,  althougii 
it  rarely  occurs  spontaneously  in  domestic  animals 
except  cattle.  The  proportion  of  slaughtered  cattle 
found  to  be  tuberculous  at  inspected  abattoirs  ranges 
from  4  to  25  per  cent.  The  butter  and  milk  of  the 
market  sometimes  contain  bacilli.  The  bovine  ba- 
cillus tuberculosis  is  shorter  than  the  human  and 
more  virulent  to  other  animals.  Rabbits  inoculated 
with  it  die  of  the  disease  in  from  seventeen  to 
twenty-one  days,  but  where  human  sputum  is  used 
they  live  from  six  to  tw^elve  weeks,  and  may  for 
a  time  thrive  and  get  fat,  and  even  bear  young.  The 
same  effect  is  found  when  cattle  are  inoculated,  but 
it  is  substantially  impossible  to  produce  tubercu- 
losis in  cattle  l)y  human  bacilli. 

That  the  bacillus  develops  spontaneously  outside 
of  the  animal  body  remains  to  be  proved,  but  the 
evidence  in  favor  of  that  possibility  is  increasing. 
It  was  the  claim  of  Koch  that  it  is  a  pure  parasite 
originating  in   the  animal  body,   and   never   spon- 


The  Bacillus  Tuberculosis  15 

taneously  a  saprophyte  existing  outside  of  it.  The 
recurrence  of  tuberculosis  in  certain  districts  and 
houses,  and  the  encouragement  of  the  growth  of  the 
bacillus  by  organic  vapors,  lead  to  the  suspicion 
that  it  can  and  does  sometimes  grow  spontaneously 
outside  the  animal  body. 

No  degree  of  cold  yet  produced  (that  of  liquid 
air,  more  than  300°  below  Fahrenheit  zero)  is 
capable  of  destroying  this  bacillus ;  after  exposure 
for  hours  to  such  a  temperature  it  will  grow  in  arti- 
ficial media.  Heat  of  82.2°  C.  (180°  F.)  promptly 
kills  it,  while  an  exposure  of  15  or  20  minutes  to 
a  temperature  of  60°  C.  (140°  F.)  destroys  it  in 
milk.'  Its  vitality  is  reduced  or  destroyed  by  pro- 
longed daylight  and  fresh  air  acting  from  five 
to  seven  days,  while  in  confined  air  it  retains  its 
virulence  for  a  long  time.  Sunshine  kills  it  after 
a  period  varying  from  one  to  twenty-four  hours, 
depending  on  the  intensity  of  the  rays  and  the  direct- 
ness of  their  effect  upon  it ;  and  the  intensity  de- 
pends on  the  clearness  of  the  atmosphere  and  its 
freedom  from  moisture,  either  visible  or  invisible. 
A  virulent  sputum  exposed  to  twelve  and  one-half 
hours  of  sunshine  dailv  for  four  days  has  failed 
after  forty-three  days  to  induce  tuberculosis  by  in- 
oculation in  gin'nea-pigs.  The  bacillus  is  destroyed 
by  strong  acids,  and  even  by  the  degree  of  acidity 

'Theobald  Smith. 


l6  Tuberculosis 

often  found  in  the  stomach  during  digestion,  by 
strong  alkahs,  and  by  germicides  in  general. 

The  bacillus  has  a  tryptic  faculty  by  which  it 
is  capable  of  transforming  various  albuminoid  sub- 
stances into  peptones  and  tryptophan.  Its  life 
power  and  its  virulence  differ  according  to  the 
animal  body  in  which  it  is  developed.  Under  cer- 
tain conditions  it  has  great  tenacity  of  life;  it  is 
even  capable  of  being  cultivated  after  it  has  been 
for  many  months  incarcerated  in  scars  in  the  animal 
body,  yet  at  times  it  is  killed  in  lung-tissues  or  old 
cavities,  the  expectorated  bacilli,  if  present,  being 
incapable  of  artificial  cultivation. 

Certain  animals  seem  to  be  perfectly  immune  to 
this  organism.  Many  are  relatively  immune  —  that 
is,  under  ordinary  conditions  of  health  they  do  not 
acquire  the  disease  when  inoculated,  but  do  acquire 
it  if  greatly  reduced  in  vitality.  This  is  an  experi- 
ence that  is  nearly  identical  with  that  of  the  human 
body,  which,  when  in  every  part  perfectly  well  and 
vigorous,  rarely,  if  ever,  takes  the  disease.  The 
blood-serum  is  germicidal  to  a  certain  degree,  as 
the  leukocytes  are,  to  this  organism.  Repeated 
propagation  of  the  bacilli  in  laboratory  media  lessens 
their  virulence  to  animals. 

Several  stainiui^  fluids  have  been  used  with  suc- 
cess for  tubercle  bacilli,  but  the  most  practical  is 
the  carbol-fuchsin  stain,  composed  of  i  part  fuch- 


The  Bacillus  Tuberculosis  17 

sin,  5  parts  carbolic  acid,  10  parts  absolute  alco- 
hol, and  85  parts  water.  (The  same  purpose  sub- 
stantially is  accomplished  by  the  following  formula : 
Saturated  alcoholic  solution  of  fuchsin,  i  part;  five 
per  cent,  watery  solution  of  carbolic  acid,  9  parts.) 
This  solution  may  be  kept  for  a  number  of  weeks, 
but  should  be  renewed  the  moment  it  shows  any 
precipitate  or  fails  to  stain  perfectly. 

For  decolorizing,  a  watery  solution  of  nitric  or 
sulphuric  acid,  10  to  20  per  cent,  may  be  used.  Or 
3  per  cent,  hydrochloric  acid  in  a  70  per  cent,  solu- 
tion of  alcohol.  The  specimen  is  immersed  in  one 
of  these  solutions  till  all  red  color  disappears  and 
till  washing  with  water  will  not  restore  it  to  any 
considerable  degree.  Then  it  should  be  washed 
free  of  acid  and  mounted,  when  the  bacilli  alone 
will  be  colored  red.  A  better  solution  is  one  that 
contains  a  contrast  stain,  whereby  with  one  pro- 
cess the  red  color  may  be  removed  from  all  parts 
of  a  specimen  excej^t  the  bacilli,  and  all  the  other 
portions  stained  blue.  One  such  solution  is  com- 
posed of  2  parts  or  less  of  methylene-blue  (not 
methyl-blue)  to  100  parts  of  a  25  per  cent,  watery 
solution  of  sulphuric  acid.  Another  solution  of 
perhaps  equal  value  is  composed  of  nitric  acid  2 
parts,  alcohol  3  parts,  and  water  5  parts,  with  llie 
addition  of  methylene-blue  to  saturation.  The  use 
of  these  solutions  leaves  the  bacilli  stained  red  in 
2 


l8  Tuberculosis 

a  blue  field,  which  facilitates  the  search  for  them 
under  the  microscope.  When  colorless  acid  solu- 
tions are  used,  a  most  excellent  counter-stain  is  a  i 
per  cent,  watery  solution  of  malachite-green,  which 
produces  instantaneously  a  beautiful  green  field, 
but  leaves  the  bacilli  with  their  red  stain  undimin- 
ished. 

The  demonstration  of  tubercle  bacilli  is  not  diffi- 
cult, and  any  student  with  an  ordinary  microscope 
outfit,  including  a  1-12  immersion  objective  and 
a  light-condenser  below^  the  stage,  can  easily  be- 
come an  expert.  A  few  tools  and  solutions  are 
necessary,  and  when  one  begins  right  and  acquires 
the  best  methods,  he  can  mount  a  specimen  for 
the  microscope  in  from  five  to  ten  minutes.  The 
things  needed  are :  a  spirit-lamp,  two  needles  fixed 
in  handles  (the  base  of  a  common  large  sewing- 
needle  forced  into  the  end  of  a  soft  piece  of  wood 
will  do),  a  Stewart  cover-glass  forceps,  an  ordin- 
ary dissecting  forceps,  thin  cover-glasses,  slides,  a 
solution  for  staining  and  another  for  decolorizing 
(or  a  contrast  stain),  and  a  bottle  of  glycerin  or 
Canada  balsam. 

The  sputum  is  best  secured,  after  rinsing  the 
mouth  thoroughly,  by  having  the  patient  expecto- 
rate into  a  clean  dish  or  a  bottle  with  a  wnde  mouth. 
Then  the  sputum  should  be  spread  out  upon  glass 
over  a  black  surface,  and  one  of  the  small  pearly 


The  Bacillus  Tuberculosis  19 

lumps  or  flecks  of  purulent  matter  that  usually 
abound  in  the  expectoration  should  be  picked  out 
with  the  needles  for  the  examination.  The  bacilli 
are  usually  found  in  these  little  particles,  but  they 
are  found  nearly  as  constantly  in  the  larger 
masses  of  pure  pus.  The  portion  selected  should 
with  needles  be  spread  on  a  cover-glass,  or  spread 
out  by  rubbing  it  between  two  of  them,  which  are 
then  pulled  apart.  It  is  best  not  to  have  the  film 
too  thin  or  too  uniform  in  thickness;  if  some  par- 
ticles are  too  thick  to  be  well  stained  and  studied 
with  the  microscope,  there  will  be  enough  other 
surface  for  study,  and  the  thicker  and  darker  spots 
will  aid  in  focusing  the  microscope.  It  is,  of 
course,  best  to  examine  sputum  soon  after  it  is  ex- 
pectorated ;  otherwise  more  or  less  decomposition 
and  granular  degeneration  will  be  found  in  it;  but 
this  will  not  prevent  the  discovery  of  the  bacilli, 
which  persist  in  spite  of  the  degeneration. 

The  film  on  the  cover-glass  is  to  be  dried  care- 
fully in  the  heat  at  a  point  a  few  inches  above  the 
flame  of  a  spirit-lamp,  when  it  may  be  passed 
through  the  flame  rather  quickly  two  or  three  times, 
to  fix  it  to  the  glass.  It  is  then  ready  for  staining, 
and  is  to  receive  from  a  pipette,  while  being  held 
level  by  the  cover-glass  forceps  (which  need  not 
let  go  its  l)ite  till  all  the  staining  process  is  done), 
enough  of  the  carbol-fuchsin  solution  to  cover  the 


20  Tuberculosis 

slip  as  deeply  as  possible  and  not  have  it  flow  off. 
This  must  now  be  heated  slowly  to  nearly  or  quite 
the  boiling  point. 

As  soon  as  this  is  accomplished  the  staining  is 
sufficient,  and  the  solution  may  be  washed  off  with 
cold  water,  and  the  decolorizing  solution  with  the 
methylene-blue  applied  immediately  and  in  the  same 
manner.  In  one  minute  this  solution  may  be  wash- 
ed off,  best  by  holding  the  cover-glass  edgewise 
or  nearly  so  in  a  stream  of  water;  then  the  speci- 
men is  dried  by  pressure  between  folds  of  soft  cloth 
or  bibulous  tissue-paper  or  by  warmth  over  the 
flame,  and  mounted  in  water  or  glycerin  for  imme- 
diate inspection,  or  in  Canada  balsam  if  it  is  to  be 
preserved.  If  the  specimen  is  to  be  kept  for  any 
length  of  time,  the  balsam  must  of  course  be  used ; 
and  if  the  acid  has  been  completely  washed  out, 
the  specimen  will  keep  indefinitely  without  deteri- 
oration ;  but  if  any  acid  remains,  it  will  sooner  or 
later  destroy  all  the  color  in  the  bacilli.  The  red 
stain  should  never  be  allowed  to  dry  on  the  cover- 
glass. 

If  a  very  careful  search  is  to  be  made  in  suspected 
sputum  containing  few  if  any  bacilli,  the  specimen 
may  be  centrifugated  for  five  minutes  (or  sedi- 
mented  by  standing  in  a  test-tube  for  a  day)  after 
its  tenacity  has  been  destroyed  by  caustic  soda,  and 
the  sediment   stained   and  examined   in   the  usual 


The  Bacillus  Tuberculosis  2i 

way.  To  liquefy  the  sputum,  water  is  added  in 
amount  depending  on  the  tenacity  of  the  sputum, 
and  then  from  i  to  5  per  cent,  of  a  saturated  aqueous 
solution  of  soda,  and  the  mixture  boiled  until  perfect 
fluidity  is  produced,  but  no  longer.  The  sediment 
secured  by  the  centrifuge  will  contain  elastic  fibers 
from  the  walls  of  the  air-vesicles  if  dissolution  of 
lung-tissue  is  going  on,  but  these  will  not  interfere 
with  the  demonstration  of  bacilli. 

In  searching  for  bacilli  in  urine  the  centrifuge 
is  used  with  a  fresh  specimen,  or  the  urine,  anti- 
septicized  with  2  to  5  drops  to  the  ounce  of  carbolic 
acid,  may  be  sedimented  for  twenty-four  hours  in  a 
deep  conical  glass  and  the  sediment  examined  in 
the  usual  way,  except  that  a  thicker  layer  of  sedi- 
ment may  be  spread  upon  the  cover-glass  than  of 
the  sputum.  The  best  way  of  all  is  to  centrifugate 
the  lowest  dram  of  the  sedimented  specimen. 

To  search  for  bacilli  in  milk  the  same  method 
may  be  used,  only  the  fat  in  the  sediment  is  a 
hindrance,  and  may  be  removed  by  immersing  the 
dried  cover-glass  preparation  in  chloroform  for  five 
minutes  before  staining.  Suspected  butter  may  be 
manipulated  thoroughly  with  a  little  water,  the 
water  being  then  centrifugated.  Any  bacilli  pres- 
ent may  be  discovered  in  the  sediment.  The  pres- 
ence of  salt  in  the  mixture  does  not  interfere  with 
the  process. 


22  Tuberculosis 

It  is  difficult  to  find  bacilli  in  the  fluid  of  pleural 
effusion  and  in  pus  from  cold  abscesses,  even  when 
tuberculosis  is  present;  but  such  fluids  injected 
into  the  peritoneal  cavity  of  guinea-pigs  usually  pro- 
duce tuberculosis. 

The  discovery  of  bacilli  in  animal  tissues  requires 
a  much  more  elaborate  process.  The  tissue  is  first 
hardened,  preferably  in  absolute  alcohol;  it  is  then 
imbedded  in  celloidin  and  cut  into  sections ;  the 
sections  are  immersed  in  oil  of  cloves  or  in  equal 
parts  of  alcohol  and  ether  to  remove  the  celloidin, 
and  are  then  put  in  alcohol,  and  finally  into  water. 
They  are  next  stained  in  carbol-fuchsin  solution, 
being  allowed  to  remain  in  the  mixture,  kept  at 
room-temperature,  for  twenty-four  hours,  although 
perfect  staining  will  take  place  in  two  hours  at  a 
temperature  of  60°  C.  (140°  F.).  They  are  then 
decolorized  In  weak  hydrochloric  acid  ( i  or  2  per 
cent.)  in  70  per  cent,  alcohol,  but  this  process  is 
not  carried  to  the  point  of  complete  decolorization. 
Contrast-staining  is  done  with  a  2  per  cent,  watery 
solution  of  methylene-blue.  Finally  the  sections 
are  dehydrated  in  alcohol,  cleared  by  oil  of  cloves 
or  xylol,  and  mounted  in  balsam. 

A  large  amount  of  experimental  work  has  been 
done  with  tubercle  1)acilli,  in  cultures  under  varying 
conditions,  through  artificial  tuberculosis  in  animals, 
and  in  efforts  to  develop  in  the  blood  of  animals  a 


The  Bacillus  Tuberculosis  23 

substance  capable  of  destroying  or  repressing  the 
bacilli  in  the  human  body. 

Certain  animals  convenient  for  the  laboratory  are 
found  very  susceptible  to  tuberculosis,  when  the 
bacilli  are  introduced  by  means  of  inoculation  of 
sputum  under  the  skin,  by  inoculation  into  the  an- 
terior chamber  of  the  eye,  or  by  injection  into  the 
peritoneal  or  pleural  cavity  or  into  the  blood-ves- 
sels. Among  these  animals  the  most  commonly 
used  are  guinea-pigs,  rabbits  and  field  mice,  named 
here  in  the  order  of  their  susceptibility.  Tuber- 
culosis of  the  lungs  has  been  produced  in  laboratory 
animals  by  causing  them  to  inhale  the  dust  of  dry, 
powdered  sputum;  by  feeding  them  on  infected 
sputum  they  have  acquired  the  disease  in  the  intes- 
tinal tract;  and  after  inoculating  a  part  of  the 
body  with  bacilli  a  local  development  of  tubercu- 
losis can  be  produced  in  a  distant  part  by  lowering 
its  vitality  in  some  w'ay,  as  through  traumatic  in- 
jury to  a  joint.  Cattle  prove  refractory  to  these 
methods  to  a  surprising  degree  when  human  sputum 
is  used. 

Where  local  inoculation  is  performed,  the  tuber- 
culous process  extends  from  this  point  by  means  of 
the  lymph-channels,  and  attacks  the  lymphatic 
glands  first  reached,  which  swell  and  pass  through 
the  several  stages  of  the  disease. 

In  efforts  to  produce  a  serum   for  the  cure  of 


24  Tuberculosis 

tuberculosis,  horses  and  other  animals  have  been 
subjected  to  repeated  hypodermic  injections  of  pure 
cultures  of  the  tubercle  bacillus,  or  of  the  products 
of  artificial  bacterial  growth,  the  dosage  being  so 
gauged  as  not  to  imperil  the  animal.  Gradually  a 
tolerance  of  the  poison  is  developed ;  larger  and 
larger  doses  can  be  endured  without  reaction,  until 
finally  the  animal  appears  to  be  immune  to  the 
poison.  Then  the  blood-serum  (secured  by  an  or- 
dinary phlebotomy)  is  separated  from  the  other  ele- 
ments of  this  fluid,  is  antisepticized  for  preserva- 
tion, and  is  prepared  for  therapeutic  use. 

The  fluid  products  of  the  artificial  growth  of  the 
tubercle  bacillus  were  first  separated  from  the  cul- 
tures by  the  discoverer  of  the  bacillus,  and  have 
become  known  as  tuberculin  or  Koch's  lymph.  The 
substance  has  come  into  extensive  use  for  diagnostic 
purposes  for  cattle,  and  to  some  extent  for  human 
subjects,  and  to  a  moderate  degree  as  a  remedy  for 
tuberculosis.  It  is  obtained  usually  from  a  glycer- 
in-bouillon culture  of  the  bacillus,  which  is  con- 
centrated to  one-tenth  volume  by  rapid  evaporation 
over  a  water-bath,  and  then  forced  through  a  por- 
celain filter  to  separate  the  dead  bodies  of  the  bacilli. 
The  fluid  is  then  preserved  by  the  addition  of  some 
antiseptic,  as  half  of  one  per  cent,  of  carbolic  acid, 
or  an  equiv^alent  amount  of  trikresol.  In  the  evap- 
oration it  is,  of  course,  the  water,  not  the  glycerin, 


The  Bacillus  Tuberculosis  25 

that  disappears,  and  so  tuberculin  is  a  rather  con- 
centrated solution  in  glycerin.  It  is  proof  against 
rather  high  temperatures;  boiling  temperature  it 
stands  well,  and  even  higher  heat  (248"^  F.).  It 
is  tolerably  constant,  and  retains  its  power  and  prop- 
erties for  a  long  time. 

One  property  of  tuberculin,  when  administered 
hypodermically  in  even  minute  doses,  is  to  produce 
fever  in  animals  and  patients  afflicted  with  any  form 
of  active  tuberculosis.  The  fever  reaction  comes 
on  a  few  hours  after  a  dose  of  i  to  5  milligrams  is 
administered,  is  attended  with  all  the  symptoms 
which  usually  accompany  fever,  and  passes  off  with 
the  usual  discomforts  a  few  hours  afterward.  Ten 
years  ago  Koch  experimented  extensively  with  tu- 
berculin on  different  forms  of  tuberculosis  in  the 
hope  of  curing  the  disease,  but  with  little  or  no 
success  except  upon  lupus. 

Tuberculin  is  used  enormously  in  many  coun- 
tries for  the  diagnosis  of  tuberculosis  in  cattle, 
and  laws  exist  in  most  of  the  states  of  our  own 
country  requiring,  under  certain  regulations,  the 
examination  of  cattle  and  the  destruction  of  those 
found  to  have  the  disease. 

Probably  there  are  several  substances  combined 
in  tuberculin  —  some  derived  from  the  bacilli,  and 
some  from  the  culture  media  —  and  it  has  fairly 
been  inferred  that  but  one  insfredient  of  the  mixture 


26  Tuberculosis 

produces  the  fever.  Repeated  efforts  have  been 
made  to  ehminate  this  ingredient,  but  with  only 
moderate  success.  Klebs  has,  as  he  believes,  pre- 
cipitated it  by  chemicals,  producing  a  substance 
which  he  has  named  aiiti-phtliisin;  also  another, 
which  is  this  substance  plus  an  extract  from  the 
bodies  of  the  bacilli,  and  which  he  has  named  tnbcr- 
ciilocidin.  These  substances  produce  less  fever  in 
tuberculosis  than  tuberculin  does. 

Koch  has  produced  two  new  tuberculin  products, 
which  he  calls  respectively  upper  tuberculin  or  T  O, 
and  tuberculin  residuum  or  T  R.  The  T  O  contains 
the  soluble  products  of  the  bacilli,  and  is  nearly  iden- 
tical with  the  original  tuberculin ;  the  T  R  contains 
the  insoluble  parts  of  the  bacilli.  In  its  manufacture 
the  bodies  of  the  dried  bacilli  are  ground  into  fine 
powder  in  a  mortar,  and  centrifugated  with  water; 
and  the  sediment  is  again  dried,  ground,  and  cen- 
trifugated, and  this  process  is  repeated  until  the 
substance  of  the  bacilli  is  rendered  soluble.  The 
fluid  of  the  first  centrifugation  is  T  O;  the  final 
product  is  T  R.  The  latter  substance  is  suspended 
in  a  20  per  cent,  solution  of  glycerin,  and  when 
injected  hypodermically  does  not  cause  abscesses. 
The  T  R  has  been  used  to  a  considerable  extent  as 
a  therapeutic  agent. 

Von  Ruck  has  produced  a  watery  extract  of  tu- 
bercle bacilli   for  a   therapeutic  agent. 


CHAPTER  II 

THE  TUBERCULOUS  PROCESS 

What  happens  in  the  human  body  infected  with 
tuberculosis?  While  there  can  be  no  tuberculosis 
without  bacilli,  tubercles  are  sometimes  absent  in 
this  disease.  Such  cases  occur  where  there  is  an 
unusual  and  rapid  dissemination  of  the  tubercle 
bacilli  throughout  the  body, —  to  such  a  degree 
that  the  patient  dies  from  the  overpowering  effect 
of  the  poisoning  before  the  tubercle  nodules  can  be 
formed. 

The  bacilli  do  not  travel  by  their  own  activity, 
so  far  as  we  know,  although  there  is  some  evidence 
that  they  have  motile  power;  but  as  they  develop 
they  spread,  because  in  their  very  multiplica- 
tion they  must  extend.  A  bacillus  divides  in  the 
center;  it  grows,  and  with  its  growth  it  pushes 
or  is  pushed  into  a  new  field.  Then  the  bacilli  are 
sometimes  moved  by  the  leukocytes  of  the  blood, 
as  they  migrate  outward  and  inward  from  the  ves- 
sels and  among  the  tissues;  and,  finding  their  way 
into  the  blood-stream,  the  bacilli  are  carried  far. 

What  usually  happens  is  the  formation  of  trans- 
lucent, grayish,  spherical  nodules  1-25  to  1-8  of  an 
inch  in  diameter,  known  as  "  tubercles,"  which  it 

27 


28  Tuberculosis 

is  a  property  of  the  bacillus  to  produce,  or  to  pro- 
voke the  tissues  to  produce.  The  nodules  accumu- 
late in  distinct  masses,  giving  an  appearance  known 
as  tubercular.  We  use  the  term  tuberculous  as 
meaning  affected  with  tuberculosis;  the  w'ord  tu- 
bercular as  meaning  filled  with  or  covered  with  little 
granular  nodules,  whether  of  tuljerculosis  or  not. 
Some  of  the  skin  diseases  are  tubercular  in  their 
appearance,  but  are  not  tuberculous. 

The  tubercles  of  this  disease  develop  rapidly  and 
crowd  into  masses  of  various  shapes  and  sizes, 
depending  on  the  tissue  and  part  invaded.  This 
endless  development  of  the  tubercles  enables  them 
very  soon  to  fill  the  center  of  the  affected  region 
so  that  it  is  one  continuous  mass,  and  the  tuber- 
cular appearance  is  lost  except  at  the  periphery. 
The  tubercles  then  develop  only  around  the  out- 
side, and  so  the  mass  spreads.  If  the  disease  occurs 
in  the  lungs,  some  of  this  substance  gets  into  the 
bronchi.  Perhaps  the  lesion  began  in  the  lining 
of  the  bronchi,  and  the  material  is  carried  along  to 
fresh  regions  by  the  movement  of  the  air  in  res- 
piration and  by  gravity,  and  so  spreads,  and  new 
foci  of  the  disease  begin. 

If  we  cut  through  a  single  tubercle  and  examine 
its  contents,  we  find  it  has  few  morphologic  ele- 
ments, and  these  substantially  constant.  Bacilli,  of 
course,  are  always  present;  two  kinds  of  cells  — 


The  Tuberculous  Process  29 

the  epithehoid  (or  endotheliod )  and  the  lymphoid; 
and  the  appearance  known  as  the  "giant-cell."  In 
histologic  examinations  the  giant-cell  has  been  usu- 
ally regarded  as  diagnostic  of  tubercle.  It  is  not 
completely  so,  since  it  is  sometimes  found  under 
other  conditions ;  but  the  presence  of  tubercle  ba- 
cilli is  diagnostic.  There  are  no  blood  vessels  in 
the  tubercle;  as  the  mass  develops  the  vessels  be- 
come plugged  up  and  disappear.  They  may  endure 
for  some  time  among  the  general  tuberculous  ag- 
gregation in  tissues  that  have  not  yet  become  com- 
pletely transformed,  but  in  the  center  of  a  mass 
that  is  wholly  composed  of  tubercles  there  are  no 
blood-vessels. 

The  giant-cell  is  a  globular  body,  made  up  of  a 
central  mass  of  granular  substance  and  around  its 
periphery  a  few  nuclei.  These  nuclei  are  never 
in  the  center.  The  center  is  a  homogeneous  sub- 
stance, and  is  probably  in  the  beginning  stage  of 
degeneration.  The  nuclei  are  the  left-over  elements 
of  the  epithelioid  cells,  both  the  cells  and  the  nu- 
clei that  occupied  the  site  of  the  center  of  the  giant- 
cell  having  lost  their  outlines  in  the  degenerative 
change.  As  we  see  the  giant-cell  under  the  mi- 
croscope it  is  in  section  or  flattened  out,  and  the 
nuclei  appear  around  its  circumference,  but  in  the 
site  of  its  growth  thev  probably  encompass  the  cen- 
tral granular  mass  completely. 


30  Tiil:)erculosis 

When  a  mass  of  tubercles  attains  anything  hke 
the  size  of  the  end  of  the  httle  finger,  it  becomes 
degenerate  in  the  center,  and  there  begins  the  pro- 
cess we  know  as  caseous  degeneration,  which  is  a| 
pecuhar  form  of  necrosis.  The  tendency  of  all 
tuberculous  nodules  is  toward  this  change  in  the 
center,  and  I  believe  the  inside  of  a  giant-cell  illus- 
trates the  beginning  of  the  process.  The  caseous 
substance  has  crudely  the  appearance  of  soft  cheese, 
hence  its  name.  Poverty  of  blood  in  the  center  of 
the  tuberculous  mass  and  lack  of  nourishment  for 
the  cells  contribute  to  the  degeneration. 

This  is  one  of  the  things  that  the  bacilli  do 
—  they  cause  the  development  of  masses  of  tuber- 
cles, and  the  plugging  of  the  vessels  so  that  the 
center  of  the  mass  loses  its  nutrition,  and  thereby 
becomes  degenerate  as  a  necessary  consequence.  In 
course  of  time  the  caseous  matter  undergoes  a  fur- 
ther degeneration  and  becomes  soft  and  semi-liquid ; 
it  has  at  first  a  battery  consistency,  then  a  more 
liquid  form ;  and  finally  chemical  changes  in  its 
substance  produce  certain  acids.  These  last  unite 
with  the  lime-salts  that  are  dissolved  in  the  blood 
and  are  present  in  this  liquid,  and  produce  small 
stony  particles,  the  calcareous  degeneration  of  the 
caseous  matter.  Patients  occasionally  expectorate 
these  little  masses  of  the  size  of  a  small  finger- 
nail or  even  larger. 


Tlie  Tuberculous  Process  31 

In  a  cavity  of  a  lung  the  bacilli  often  die.  They 
also  die  in  the  center  of  a  tuberculous  mass;  and 
if  a  compact  pile  of  tubercles  is  examined,  it  will 
be  found  that  the  bacilli  thrive  most  around  the 
outside,  where  they  can  find  the  nourishment  they 
require;  they  cannot  find  it  in  the  center  of  the 
mass.  We  have  heretofore  found  that  acid  sub- 
stances are  inimical  to  tubercle  bacilli.  Acids  are 
produced  in  the  degeneration  of  tuberculosis,  and 
probably  kill  many  bacilli,  wdiile  more  die  from 
want  of  adequate  nutriment.  In  the  growth  of 
pure  cultures  the  organisms  develop  something  that 
destroys  themselves, —  a  thing  that  is  illustrated  by 
the  history  of  most  other  germs.  As  the  tuber- 
culous mass  spreads,  it  often  produces  more  or  less 
ordinary  inflammation,  so  we  have  that  added  to 
the  tuberculous  process. 

Not  only  is  there  development  of  tubercles  in  a 
mass,  but  the  disease  occurs  on  surfaces  —  the  skin 
and  mucous  and  serous  membranes  —  where  no  such 
aggregations  can  be  formed.  In  the  mass,  degen- 
eration goes  on  in  the  center;  on  the  surfaces, 
ulcers  are  often  produced  instead,  as  in  lupus  and 
intestinal  ulceration.  Degenerate  masses  are  ex- 
truded, and  the  products  of  the  disease  are  cast 
off  as  they  form.  The  products  of  the  ulceration 
represent  what  in  a  parenchymatous  organ  is  the 
caseous  center  of  a  degenerate  mass.     In  surface 


^2  Tuberculosis 

tuberculosis  the  disease  sometimes  remains  quite 
superficial,  but  sometimes  it  burrows  rather  deeply. 

Inflammation  often  occurs  around  the  tubercu- 
lous areas.  Not  only  this,  1)ut  that  which  usually 
happens  in  inflammatory  processes  —  namely,  the 
growth  of  pus  microbes.  Hence  we  have  purulent 
discharge  from  the  ulcers  and  from  the  cavities 
produced  by  the  liquefaction  of  a  tuberculous  mass, 
and  the  patient  absorbs  some  of  the  products  of 
this  suppuration ;  as  a  consequence,  more  or  less 
general  infection  ensues.  There  result  chills,  fever, 
and  sweating  of  various  degrees,  which  we  recog- 
nize as  belonging  in  some  way  to  the  disease  known 
as  septicemia  or  pyemia.  This  subject  we  will 
discuss  later  on.  I  may  say,  however,  that  most 
of  the  deaths  from  tuberculosis  are  produced  by 
this  septic  poison.  The  poisoning  and  the  fever 
wear  the  patient  out.  These  cases  represent  what 
is  called  mixed  infection  —  infection  from  pus  mi- 
crobes and  tubercle  microbes  and  their  products. 
There  is  reason  to  suppose  that  the  high  fever  of 
pulmonary  tuberculosis  is  always  caused  by  pus 
products.  ]Many  other  kinds  of  fever  are  produced 
in  this  manner. 

Nearly  all  the  tissues  of  the  body  are  obnoxious 
to  tuberculosis.  One  of  the  most  resistant  of  them 
is  the  walls  of  blood-vessels,  and  yet  these  become 


The  Tuberculous  Process  33 

involved,  grow  friable,  and  break  easily.  The  usual 
blood-pressure  within  ruptures  them,  and  so  we 
have  the  hemorrhages  of  consumption.  j\Iany 
times  the  tuberculous  ulcers  and  cavities  heal.  They 
heal  with  a  thick  mass  of  scar-tissue,  within  which 
great  numbers  of  bacilli  are  imprisoned.  The  scars 
are  weak  for  a  long  time,  and  it  is  never  safe  to 
regard  a  lesion  as  cured  until  the  scar  is  a  year 
or  more  old.  The  process  that  goes  on  to  make 
the  scar  is  a  conservative  one  —  nature's  invention 
evidently  for  abbreviating  the  disease  —  and  we  call 
it  fibrosis. 

When  a  tuberculous  deposit  occurs  in  the  lungs, 
the  fibrous  tissue  of  the  trabecular  structure  of 
the  organ  round  about  usually  begins  to  thicken, 
and  the  process  goes  on  in  a  progressive  manner, 
increasing  in  lines  radiating  from  the  center,  so 
that  as  we  examine  the  lung  from  time  to  time  we 
can  demonstrate  that  the  fibrosis  has  extended  far 
beyond  the  area  of  the  tuberculosis.  Fibrosis  is 
most  marked  directly  around  the  mass  of  tuber- 
culous infiltration ;  but  it  reaches  out  into  the  nor- 
mal tissue,  shading  off  to  the  perfectly  nor- 
mal lung-substance  some  distance  away.  It  helps 
to  limit  the  process  of  tuberculosis,  and  it  occurs 
in  all  degrees  from  the  slightest  quantity  of  fibrous 
tissue  to  the  most  profound  dissemination  of  it 
through  the  lungs,  producing  that  form  which  we 
3 


34  Tuberculosis 

know  as  fibroid  p/itliisis.  The  fibrosis  probably  con- 
tinues to  increase  for  some  time  after  the  tubercu- 
losis is  healed  —  after  it  has  segregated  the  tuber- 
culous mass  from  the  circulation  and  lymphatics, 
and  after  a  tuberculous  cavity  has  been  opened  into 
a  bronchus  and  is  regularly  evacuated.  In  such 
cases  the  fever  may  cease  and  the  patient  improve, 
but  the  fibrosis  continues  to  spread.  If  in  a  case 
of  pulmonary  tuljerculosis  the  fibroid  change  fails 
to  take  place,  we  know  that  the  patient  is  in  greater 
peril  in  consequence,  that  the  disease  is  more  likely 
to  spread,  and  that  nature  has  failed  to  throw  around 
the  lesion  any  barrier  to  prexent  its  spread. 

If  we  were  to  make  a  list  of  the  tissues  more 
commonly  invaded  by  tuberculosis,  somewhat  in 
the  order  of  their  susceptibility,  it  might  be  roughly 
as  follows :  Lymphatic  glands,  bronchi,  bronchi- 
oles, lung-tissue,  pleura,  joints,  larynx,  peritoneum, 
testicles,  intestines,  bones,  cerebral  meninges,  urin- 
ary bladder,  kidneys,  skin,  adrenals,  muscles,  nerve- 
sheaths,  and  blood-vessel  walls. 

Numerous  complications,  apparent  and  real,  occur 
in  this  disease.  It  is  a  question  as  to  many  of  the 
so-called  complications  whether  we  should  not  con- 
sider them  as  evidences  of  the  usual  spread  of  the 
disease.  For  instance,  at  the  beginning  the  dis- 
ease appears  in  the  surface  of  the  lining  of  a  l)ron- 
chial  tube;    it  cxtciuls  to  the  submucous  tissue  and 


The  Tuberculous  Process  35 

then  into  the  king-tissue;  the  bacilH  get  into 
the  circulation  and  start  to  grow  in  a  kidney  or 
an  epididymis;  the  trachea  is  covered  more  or  less 
with  them ;  they  lodge  there  and  are  expectorated 
to  a  large  degree;  they  remain  for  hours  along 
the  lining  of  the  windpipe;  frequently  they  are 
aspired  back  into  a  healthy  bronchus,  where  they 
start  a  new  focus  of  disease;  sometimes  by  a  spas- 
modic cough  they  are  carried  into  the  post-nasal 
region ;  more  or  less  phlegm  lodges  on  the  hands 
and  gets  into  cuts  and  abrasions,  and  so  starts 
a  skin  lesion.  Tuberculosis  of  the  larynx  may  set 
in,  and  extend  up  into  the  pharynx ;  the  bacilli  may 
be  swallowed;  if  there  is  sufficient  acid^  in  the 
stomach,  it  destroys  them;  if  not,  they  pass  down 
the  digestive  tube,  to  produce  possible  ulcers  of 
the  intestines.  We  ought  hardly  to  say  that  these 
examples  are  complications;  they  are  due  rather 
to  the  natural  spread  of  the  disease  in  a  body  whose 
resisting  power  to  the  bacilli  is  lowered. 

The  disease  begins  oftenest  in  the  upper  part 
of  the  right  lung.  That  sometimes  recovers  with 
the  formation  of  fibrous  tissue;  then  the  disease 
appears  in  or  near  the  apex  of  the  left  lung.  This 
we  recognize  as  probably  due  to  the  aspiration  of 
the  bacilli-laden   phlegm   into  the   larger  bronchus 

1  There  is  reason  to  believe  that  the  usual  degree  of  acidity 
of  the  gastric  contents  is  not  sufficient  to  repress  tubercle 
bacilli   to  any   great  extent. 


^C)  Tuberculosis 

of  the  left  side.  Again,  the  kidneys  become  in- 
volved, the  epididymis,  the  joints,  the  sheaths  of 
tendons,  and  we  are  apt  to  say  that  these  are  com- 
plications; but  they  really  are  only  examples  of  the 
spread  of  the  disease.  The  joints  swell,  often  too 
the  sheaths  of  tendons  and  the  fibrous  tissues  about 
them,  and  the  patients  say  they  have  rheumatism ; 
but  these  are  the  legitimate  results  of  the  disease 
in  patients  who  are  unable  to  resist,  who  have  lost 
the  power  to  destroy  the  microbes.  There  is  no 
doubt  that  the  bacilli  permeate  every  part  of  the 
body  sooner  or  later.  They  find  in  the  blood,  of 
course,  substances  inimical  to  them,  and  if  the  nu- 
trition and  general  resisting  power  of  the  patient 
are  fairly  good,  they  are  destroyed ;  but  they  grow 
and  thrive  if  the  nutrition  and  the  resisting  power 
are  poor. 

The  epididymis  is  very  susceptible  to  this  infec- 
tion, though  the  testicle  proper  is  rarely  involved. 
The  movement  of  fluid  from  the  epididymis  into 
the  vesiculae  seminales.  bladder,  and  urethra  often 
causes  an  extension  of  the  tuberculosis  to  these 
parts;  and  when  the  bladder  is  invaded,  the  dis- 
ease sometimes  travels  up  into  the  kidneys  by  exten- 
sion, as  well  as  through  the  l)lood  in  a  manner 
similar  to  that  in  which  it  first  reached  the  epi- 
didymis and  the  joints. 

One  of  the  most  common  forms  of  the  disease 


The  Tuberculous  Process  37 

that  we  have  to  deal  with  is  pleurisy.  Alost  pleu- 
risies are  tuberculous.  This  cannot  be  demonstrated 
in  the  fluid  very  readily,  but  inoculation  of  guinea- 
pigs  with  it  generally  produces  the  disease.  Serous 
membranes  are  in  a  way  more  resistant  than  other 
tissues  of  the  body,  and  the  pleura  frequently  re- 
covers permanently  and  no  general  infection  occurs, 
perhaps  because  for  anatomic  reasons  absorption 
into  the  general  circulation  is  less  here  than  from 
most  other  tissues. 

Many  of  the  cases  of  peritonitis  that  formerly 
were  known  by  a  variety  of  other  names  are  noth- 
ing but  tuberculosis.  This  form  recovers  in  a  cer- 
tain percentage  of  cases,  sometimes  by  rest  and 
a  fresh  increment  of  resisting  power,  sometimes  by 
surgical  aid. 

There  is  a  form  of  tuberculosis  of  the  skin  of 
recent  discovery,  known  as  anatomic  tuberculosis. 
It  produces  a  roughness  of  the  skin  and  thickening 
that  resembles  chapping  of  the  hands.  It  spreads, 
thickening  the  skin  a  little,  and  is  very  persistent. 
Men  performing  surgical  operations,  dissecting,  and 
making  post-mortem  examinations  occasionally  ac- 
quire it.  The  tissues  of  disease  contain  but  few 
bacilli. 

The  rather  unusual  affection  called  In-onzed  skin 
or  Addison's  disease,  known  for  many  years  to 
be  associated  with  lesion  of  the  adrenals,  we  now 


38  Tuberculosis 

know  to  be  due  generally  to  tuberculosis  of  these 
organs.  The  disease  is  characterized  by  great  pros- 
tration, profound  weakness  (patients  usually  dying 
of  it),  and  by  bronzing  of  the  skin  if  the  patients 
live  long  enough.  The  skin  becomes  dark  in  spots, 
particularly  those  portions  of  the  surface  exposed 
to  the  light,  and  pigmented  parts  not  so  exposed,  as 
the  genitalia  and  the  area  about  the  nipples. 

Therefore,  from  a  few  forms  of  tuberculosis  with 
which  the  study  of  the  disease  started,  we  easily 
discover  numerous  forms;  and  doubtless  other  af- 
fections, heretofore  known  by  quite  different  names, 
will  be  found  to  be  only  variations  of  this  wonder- 
ful disease. 


CHAPTER  III 

FORMS    OF   TUBERCULOSIS 

Tuberculosis  attacks  numerous  tissues  of  the 
body.  It  often  docs  this  in  the  course  of  its  spread 
from  a  single  focus.  For  example,  in  lung  tuber- 
culosis there  is  frequently  a  middle  ear  infection. 
The  drum  becomes  inflamed,  breaks  down  in  ulcer- 
ation, and  a  perforation  results.  Sometimes  the 
mastoid  cells  become  involved.  These  complica- 
tions may  improve  and  go  on  to  recovery  with  more 
or  less  deafness.  The  mucous  membranes  are  spe- 
cially prone  to  this  disease.  In  a  proportion  of 
cases  the  larynx  becomes  involved  —  very  rarely  in 
a  primary  way,  nearly  always  consecutive  to  the 
lung  disease.  Laryngeal  tuberculosis  does  not  im- 
ply that  the  patient  has  carried  through  the  larynx 
an  unusual  amount  of  bacillary  phlegm  and  so  has 
infected  it,  but  rather  that  the  resisting  power  of 
the  part  and  of  the  patient  is  low. 

There  are  two  noticeable  forms  of  laryngeal  tu- 
berculosis. In  one  form  there  is  roughening  and 
ulceration  of  the  vocal  cords,  producing  aphonia, 
which  is  not  dangerous  and  from  which  the  i)alicnt 
may  recover;  in  the  other  form  the  arytenoid  regions 
and  the  posterior  structures  of  tlic  larynx  become 
.  39 


40  Tuberculosis 

more  particularly  affected.  In  the  latter  condition 
there  are  pain,  swelling,  and  perhaps  ulceration, 
sometimes  but  not  always  aphonia,  and  nearly  al- 
ways painful  deglutition. 

The  disease  may  spread  to  the  trachea,  rarely  to 
the  esophagus  and  stomach,  and  to  the  bowels,  ure- 
thra, prostate  gland,  and  kidneys.  Fistula  in  ano, 
which  occurs  in  many  cases  of  consumption,  may 
or  may  not  at  first  be  tuberculous,  but  usually  it 
becomes  so  sooner  or  later.  It  is  one  of  the  re- 
sults of  abscess  by  the  side  of  the  rectum,  caused  by 
the  extension  of  microbic  growth  through  the  mu- 
cous membrane  from  this  reser\'oir.  This  latter 
event  is  made  possible  by  the  general  reduction  in 
bodily  vigor  and  by  the  local  irritation  due  to  reten- 
tion of  fecal  matter  and  to  filthy  conditions  of  the 
parts. 

The  serous  membranes,  the  pleura,  meninges,  and 
peritoneum  especially,  are  often  involved.  Tuber- 
culous cerebral  meningitis  is  a  form  that  is  substan- 
tially always  mortal.  It  occurs  in  children  mainly, 
rarely  in  adults,  save  as  a  terminal  event  in  con- 
sumption. In  children  it  may  apparently  be  inde- 
pendent of  tuberculosis  elsewhere,  but  it  is  probably 
nearly  always  secondary.  The  bacilli  in  some  way 
enter  the  blood-vessels  and  reach  the  membranes 
of  the  brain,  and  through  the  capillaries  produce 
meningitis.     As  to  the  peritoneum  and  pleura,  the 


Forms  of  Tuberculosis  41 

connective  tissue  beneath  these  membranes  becomes 
involved.  The  dense  cartilages,  the  skin,  and  even 
the  muscles  including  the  heart  may  be  affected; 
so  also  may  the  lymphatic  glands  and  the  various 
secreting  organs,  as  the  kidneys,  adrenals,  liver, 
spleen,  pancreas,  and  testicles. 

There  are  two  forms  of  tuberculosis  of  the  skin 
—  lupus  and  anatomic  tubercle.  This  latter  occurs 
mostly  on  the  hands,  is  probably  due  to  direct  in- 
fection, and  has  the  appearance  of  thickened  plaques 
and  warts. 

Bone  tuberculosis,  a  surgical  variety  not  to  be 
discussed  at  any  length  here,  is  often  attended  with 
necrosis.  The  spongy  structure  of  the  bone  is  most 
likely  to  be  affected,  as  the  bodies  of  the  vertebrae, 
where  it  produces  angular  curvature  of  the  spine. 
Osteomyelitis  of  the  long  bones  is  not  infrequently 
tuberculous,  and  leads  to  various  surgical  incidents 
and  deformities. 

The  joints  are  involved  frequently,  the  hip  and 
knee  especially.  The  hi])  disease  known  as  morbus 
coxarius  and  white  swelling  of  the  knee  are  usually 
tuberculous.  The  tendon-sheaths  become  involved, 
those  of  the  wrists  most  frequently,  and  attached 
to  their  surfaces  minute  rice-like  bodies  appear  in 
great  clusters,  with  swelling  and  some  pain,  espe- 
cially on  motion.  These  bodies,  like  the  structure 
of  fibrosis,  are  mostly  fibrous  material. 


42  Tuberculosis 

The  disease  of  the  glands  of  the  mesentery  known 
as  tabes  niesenterica  is  generally,  if  not  always, 
tuberculous.  It  is  infrequent,  occurs  mostly  in 
children,  and  is  usually  mortal.  Swelling  of  the 
glands  of  the'*'neck  wntli  abscesses,  followed  by  pro- 
tracted supi:)uration  and  the  formation  of  ugly  scars, 
is  a  common  affection,  and  is  known  by  the  general 
name  of  scrofula.  This,  too,  is  an  affection  of  child- 
hood, and  is  now  proven  to  be  almost  invariably 
tuberculous.  It  is  probably  always  secondary  to 
infection  of  the  tonsils.  It  is,  to  my  mind,  a  cu- 
riosity in  pathology  that  lymphatic  glands  can  be- 
come tuberculous,  suppurate,  even  break  open  spon- 
taneously, discharge  for  a  long  time,  recover,  and 
the  patients  never  afterward  have  tuberculosis  other- 
wise or  elsewhere.  The  tuberculous  character  of 
these  cases  would  be  doubtful  if  the  proof  on  this 
point  were  less  positive. 

"  Miliary  tuberculosis  "  usually  is  taken  to  mean 
a  general  sudden  explosion  of  tuberculosis  through- 
out many  parts  and  tissues  of  the  body,  with  high 
fever.  But  as  it  is  referred  to  in  text-l)ooks  it  is, 
I  am  sure,  a  misleading  idea.  In  the  descriptions 
of  fevers  and  the  rules  for  diagnosis  of  febrile  con- 
ditions as  set  forth  in  the  literature  of  medicine 
general  miliary  tuberculosis  is  regarded  as  one  of 
the  causes  of  suddenly  occurring  high  fever,  and  we 
are  asked  to  balance  the  evidence  between  this  and 


Forms  of  Tuberculosis  43 

typhoid  fever,  malarial  fever,  and  some  other  in- 
fections, in  a  search  for  the  pathology  of  an  attack. 
But  the  affection  very  rarely  produces  high  fever 
except  as  a  terminal  disorder  or  complication  in  a 
patient  profoundly  poisoned  with  tuberculosis  or 
greatly  prostrated  by  some  other  disease.  It  may 
in  the  lungs  be  chronic,  and  attended  with  little 
fever,  and  it  is  not  at  all  uncommon  for  numerous 
organs  to  be  involved  within  a  short  time,  as  a 
terminal  event.  With  a  circumscribed  deposit  of 
tuberculosis  a  patient  may  resist  the  disease  for  a 
long  time ;  but  finally  it  spreads  a  little,  vitality 
becomes  lower,  cachexia  creeps  on,  when  suddenly 
numerous  organs  and  tissues  become  infected  within 
a  few  days,  and  death  ensues  speedily.  And  this 
may  occur  with  little  fever,  and  that  little  very 
irregular.  The  frequency  of  such  terminal  events 
in  this  disease  recalls  what  an  eminent  writer  has 
said  in  a  general  way  —  that  "  it  is  rare  for  people 
to  die  of  the  diseases  that  have  afflicted  them." 

The  lungs  are  the  chief  seat  of  tuberculosis  as 
a  medical  disease,  and  I  am  sure  that  most  of  us 
have  had  an  imperfect  conception  of  its  behavior 
in  these  organs.  We  may  profitably  classify  the 
disease  under  a  number  of  forms  as  it  occurs  in 
the  lungs  and  olhcr  organs,  for  this  will  hel})  to  a 
clearer  understanding  of  its  variations.  But  nature 
makes  no  such  sharj:)  lines  of  classification  as  our 


44  Tuberculosis 

grouping  would  suggest.  These  types  merge  more 
or  less  into  each  other;  but  the  want  of  some  divi- 
sion of  this  sort  is  to  some  extent  responsible  for 
the  habit  of  assuming  that  all  cases  of  lung  tuber- 
culosis must  follow  about  the  same  course  —  a  habit 
that  has  led  us  into  many  mistakes  and  done  much 
harm  to  the  patients.  Lung  tuberculosis  is  a  most 
variable  disease  in  its  manifestations  and  course. 

First  let  us  consider  the  fibrous  form,  in  which 
there  is  a  great  deal  of  fibrosis,  where  the  lesion 
begins  on  the  mucous  surface,  and  the  fibrosis  starts 
beneath  it.  The  fibrous  tissue  of  the  lung  becomes 
thickened.  The  same  material  is  deposited  there 
as  in  scar-tissue,  and  this  extends  widely  in  all 
directions  and  far  from  the  seat  of  the  bacillary 
deposit.  There  is  very  little  breaking  down  of  the 
lung  into  masses  of  degeneration  or  into  cavities. 
There  is  little  of  the  caseous  degeneration  and 
relatively  little  suppuration  or  mixed  infection.  The 
progress  of  the  cases  is  slow.  The  diseased  lung 
contracts  greatly,  and,  as  there  is  little  suppuration, 
there  is  little  absorption  of  pus  products,  and  rarely 
much  fever.  The  cases,  as  a  rule,  are  unilateral 
at  the  beginning,  and  often  remain  so.  Sometimes 
both  lungs  become  involved,  the  second  one  usually 
in  a  less  severe  way.  If  the  disease  is  confined 
to  the  left  lung,  it  presents  an  interesting  ])icture  of 
the  uncovered  heart  with  its  pulsations  seen  through 


Forms  of  Tuberculosis  45 

the  third  and  fourth  costal  interspaces.  E\en  the 
movements  of  the  auricle  can  often  be  plainly  seen. 
The  measurement  of  the  chest  shows  marked  con- 
traction and  there  is  reduced  motion  on  the  affected 
side.  The  cases  frequently  pass  into  a  condition 
that  we  call  recovery;  but  it  is  somewhat  ques- 
tionable whether  the  recovery  is  complete,  because 
there  is  always  imbedded  within  the  fibroid  tissue 
many  bacilli  that  retain  their  vitality  for  some  time, 
and  if  the  tissue  breaks  down,  they  are  liable  to 
multiply  and  reinfect  the  patient.  This  form  may 
exist  for  a  long  time  with  slight  physical  changes, 
although  there  is  always  some  debility  and  short- 
windedness. 

The  second  form  differs  radically  from  the  first 
in  the  fact  that  there  is  always  a  sharply  circum- 
scribed deposit  of  tuberculosis.  Most  often  it  is 
in  the  apex  of  a  single  lung,  and  the  physical  signs 
are  marked.  The  fibrosis,  which  is  usually  consid- 
erable, is  within  and  around  the  location  of  the 
disease,  rarely  diffused  widely  throughout  the  lung. 
This  form  shows  the  effective  and  economical  means 
that  nature  employs  to  abbreviate  the  disease.  It 
throws  a  barrier  around  the  affected  area  that  seg- 
regates it  from  the  rest  of  the  lung-tissue.  Cavi- 
ties may  occur,  suppuration  take  place,  and  caseous 
matter  and  even  calcareous  granules  may  be  ex- 
pelled, and  yet  the  sequestration  of  the  mass  may 


46  Tuberculosis 

be  so  secure  tbat  other  portions  of  the  lungs  and 
body  escape  completely.  These  patients  frequently 
recover  with  contractures  and  moderate  lessening 
of  breathing  capacity. 

The  third  form  is  the  same  as  the  second  except 
that  little  or  no  fibrosis  occurs.  The  lung-tissue 
at  some  point  becomes  profoundly  involved,  cavities 
result,  there  is  high  fever  from  pus  absorption, 
and  no  tendency  to  recover.  These  cases  consti- 
tute what  is  known  as  quick  or  galloping  consump- 
tion. They  all  die :  where  there  is  no  tendency 
to  fibrosis  there  is  no  chance  to  recover.  Such 
patients  frequently  die  before  the  other  organs  are 
involved.  They  die.  as  a  rule,  of  an  overpowering 
mixed  infection,  and  not  from  the  extension  of 
the  disease  to  other  organs. 

There  is  a  fourth  form  in  which  the  disease  is 
slight  and  is  confined  to  one  lung  for  years,  with 
no  extension  to  other  organs  and  with  little  effect 
on  the  general  nutrition.  Fibrosis  is  considerable; 
there  is  little  or  no  fever,  and  the  patients  pass 
for  healthy  people.  I  believe  that  in  many  of 
these  cases  the  disease  is  confined  to  the  bronchial 
mucous  membrane  almost  exclusively.  The  lining 
of  a  bronchus  may  be  a  culture  field  for  bacilli  for 
a  long  time.  The  mucous  formations  and  other 
products  of  the  disease  are  in  small  amount  and 
rarely  expectorated.     There  is  often  only  moderate 


Forms  of  Tuberculosis  47 

fibrosis  with  slight  contraction  of  the  lung,  and  such 
slight  change  in  the  tissues  that  the  patients  pass  for 
persons  in  health.  Their  condition  is,  however, 
easily  discovered  if  they  happen  to  run  or  to  make 
violent  exertion,  for  they  are  slightly  short-winded, 
showing  that  the  lung-capacity  is  impaired  to  some 
degree.  They  complain  of  frequent  colds.  They 
cough  immediately  on  getting  below  their  usual 
physiologic  standard ;  this  is  their  "cold,"  and  on 
resting  and  recuperating  the  "  cold "  passes  off. 
They  may  have  with  these  attacks  a  slight  rise  of 
temperature  —  not  enough  to  impair  nutrition  much, 
and  so  it  does  not  lower  their  general  health.  They 
sometimes  even  gain  in  weight  and  are  heavier 
than  before  they  had  the  disease.  They  live  for 
years,   and  sometimes  recover  completely. 

The  fifth  form  is  that  in  which  the  disease  is 
confined  to  the  lungs  at  first  and  then  spreads  to 
other  organs  —  the  stomach,  intestines,  kidneys,  tes- 
ticles, larynx,  ears,  prostate  —  in  fact  becomes  a 
general  infection,  and  death  always  results.  These 
are  the  cases  in  which  there  is  very  little  natural 
resisting  power,  or  where  the  patients  are  under 
extremely  adverse  physiologic  and  hygienic  condi- 
tions. They  may  resist  the  disease  for  a  little  time 
after  it  attacks  the  lungs,  when  it  appears  to  belong 
to  the  second  form ;  but  soon  there  is  a  rapid  spread 
of  the  disease  to  other  organs. 


48  Tul3erculosis 

The  sixth  form  is  the  most  decepti\-e  of  all.  and 
particularly  so  to  the  young  practitioner.  It  has 
a  symptomatology  of  the  lungs  that  leads  generally 
to  a  mistaken  diagnosis.  It  might  be  called  the 
fibrous  and  dissolving  form.  Diffused  moderate 
fibrosis  occurs,  disseminated  dissolution  of  the  lung- 
tissues  and  almost  no  rales  or  expectoration.  The 
fibrosis  develops  in  and  about  the  tuberculous 
masses,  and  the  latter  have  a  diffused,  non-solid 
form.  They  contract  to  the  degree  necessary  to 
choke  the  blood-vessels  that  supply  the  septa  be- 
tween the  air-vesicles.  As  a  result,  many  of  the 
septa  break  down  and  are  absorbed.  Thus  tw^o  or 
more  vesicles  are  thrown  into  one,  the  respiratory 
space  is  reduced,  and  in  consequence  the  patient 
breathes  more  rapidly.  There  is  reduced  oxygen- 
ation and  reduced  vitality.  These  patients  do  not 
expectorate,  or  expectorate  little,  and  of  thick,  yel- 
low material.  There  is  no  dulness  on  percussion, 
but  great  resonance  everywhere;  generally  both 
lungs  are  more  or  less  involved,  and  they  are  about 
equally  resonant.  If  both  lungs  are  not  involved, 
then  the  unaffected  one,  having  to  do  more  duty, 
develops  puerile  sounds,  and  hence  resonance  on 
percussion  over  both  sides  is  loud;  auscultation  re- 
veals puerile  breathing,  and  so  the  doctor  is  con- 
fused. The  patient  coughs,  there  is  loud  reson- 
ance  on   percussion,    no   bronchial   breathing   any- 


Forms  of  Tuberculosis  49 

where,  not  a  rale  to  be  heard,  and  the  physician  is 
likely  to  think  that  the  case  cannot  be  one  of  tuber- 
culosis. He  finds  that  his  patient  is  low  in  vitality, 
has  a  little  fever  and  disorder  of  digestion  and 
therefore  he  is  tempted  to  refer  the  symptoms  to 
some  affection  of  the  stomach  or  general  nutrition. 
But  the  patient  is  breathless,  and  if  the  doctor  lis- 
tens carefully,  he  finds  with  a  variety  of  loud  lung- 
sounds  that  the  true  vesicular  murmur  is  greatly 
reduced.  The  disease  progresses  slowly  but  stead- 
ily, and  if  by  persistent  efforts  the  patient  succeeds 
in  bringing  up  a  little  si:)eck  of  yellow  phlegm,  it 
is  found  to  be  teeming  with  tubercle  bacilli.  This 
form  is  steadily  progressive,  and  the  patients  all 
die  of  it,  if  not  cut  off  by  some  intercurrent  disease. 

There  is  a  se^'enth  class,  composed  of  cases  that 
begin  with  a  tuberculous  deposit  in  the  right  apex, 
and  which  recover  with  some  consolidation  and 
contraction,  to  be  followed  by  a  deposit  in  the  upper 
part  of  the  left  lung.  In  some  of  these  cases  the 
left-sided  infection  gets  well  or  death  ensues  with- 
out the  right  side  breaking  out  again.  This  class 
is  not  very  numerous,  but  sufficiently  so  for  iden- 
tification. I  do  not  remember  to  h^xe  seen  the 
reverse  of  the  experience  —  that  is,  where  the  left 
apex  became  infected  and  recovered,  to  be  followed 
by  infection  of  the  right  apex. 

There  is  an  eighth  class  of  patients  who  ha\c 
4 


50  Tuberculosis 

wide  and  extensive  deposits  of  tubercles  scattered 
rather  uniformly  over  a  large  part  of  a  lung  or 
both  lungs,  with  almost  no  pus  formation,  little  or 
no  expectoration,  and  only  a  little  fever,  which 
may  occur  irregularly.  There  may  be  some  dul- 
ness  on  percussion ;  sometimes  the  dulness  is  mark- 
ed. There  are  a  few  fine  and  faint  scattered  rales, 
heard  most  on  inspiration.  There  is  always  great 
dyspnea  and  a  rapid  heart-beat.  Sometimes  the 
condition  is  secondary  to  a  rather  long  existing 
quiescent  tuberculosis  in  a  circumscriljed  lung  area; 
sometimes  it  appears  to  be  primary.  As  there  is 
little  pus,  mixed  infection  is  rare.  The  patients 
all  die  eventually,  but  some  remain  at  a  standstill 
for  a  long  time.  This  form  of  tuberculosis  is  often 
misleading  to  the  ^iractitioner,  but  is  very  instruc- 
tive. It  proves,  as  injections  of  Koch's  lymph  do, 
that  the  pure  infection  of  tuberculosis  may  cause 
fever,  the  irregular  fever  of  these  cases  probably 
being  due  to  the  intermittent  discharge  of  the  tu- 
berculin into  the  current  of  the  circulation. 

A  most  proper  name   for  this  form  of  disease 
would  be  "  miliary  tuberculosis." 


CHAPTER  IV 

THE    PATHOLOGY    OF    TUBERCULOSIS 

There  are  a  few  principles  that  should  be  kept 
distinctly  in  mind  as  to  the  pathology  of  this  disease. 
The  tubercle  bacillus,  like  all  germs,  grows  with  dif- 
ficulty except  under  favoring  conditions.  It  finds 
a  good  culture  field  in  many  tissues  and  organs  of 
animal  bodies.  Normal  tissues  of  the  human  body, 
and  especially  blood,  are  inimical  to  the  growth 
of  it,  and  the  blood  that  is  shed  appears  to  be  most 
so.  As  long,  therefore,  as  the  blood  in  the  body 
can  be  kept  up  to  a  strictly  normal  standard,  a 
great  number  of  bacilli  may  be  thrown  into  its 
current  and  carried  to  distant  organs  without  start- 
ing tuberculous  growths  in  any  of  them.  The 
blood  will  kill  the  bacilli  if  its  normal  state  is 
maintained.  The  vigor  of  the  constitution  must 
be  lowered  where  tuberculosis  spreads  through  the 
blood-current.  It  has  long  been  known  that  patients 
with  pulmonary  tuberculosis  w4io  have  occasional 
slight  hemorrhages  are  more  likely  to  recover  than 
others. 

A  patient  will  often  make  a  sudden  slight  im- 
provement after  a  moderate  hemorrhage.  We  were 
at  a  loss  to  understand  why  this  was  so  until  it  was 

SI 


5-  Tujjerculosis 

discovered  that  the  blood  outside  of  the  vessels 
has  a  power  more  destructive  to  microbes  than  that 
inside.  Blood  -  vessel  walls  in  the  course  of  the 
disease  become  invaded  and  rupture;  the  blood 
flows  out  and  surrounds  these  broken  vessels,  fills 
the  cavities,  flows  along  the  bronchi,  and  doubtless 
kills  many  of  the  bacilli.  It  is  true  that  it  also 
washes  away  some  of  the  products  of  the  disease 
and  helps  to  get  them  out  of  the  body,  which  is 
useful  so  far  as  it  goes. 

There  are  different  degrees  of  antagonism  to 
tuberculosis  in  difi^erent  human  bodies;  some  have 
a  great  deal,  and  some  have  very  little.  Different 
ages,  the  sexes  perhaps,  and  different  races  all 
have  their  variations,  and  there  is  a  marked  varia- 
tion in  hereditary  susceptibility.  Very  young  per- 
sons or  children  with  tuberculosis  of  the  lungs 
sometimes  show  relatively  great  resisting  power. 
A  child  of  twelve  years  with  tuberculosis  of  the 
lungs  may  go  on  to  maturity,  resisting  the  inroads 
of  the  disease,  and  recover.  There  seems  to  be 
something  in  the  physiologic  evolution  of  develop- 
ing tissue  that  increases  the  protecting  substance  in 
the  blood.  Let  a  person  contract  the  disease  at 
eighteen  or  twenty  years  of  age,  and  it  will  be 
more  likely  to  terminate  fatally;  but  if  the  disease 
comes  on  at  thirty  or  forty,  the  likelihood  of  re- 
covery will  be  much  greater. 


The  Patlioloe:v  of  Tuberculosis 


'S,* 


It  may  therefore  be  said  that  the  normal  resist- 
ing power  must  become  lowered  in  a  part  before  the 
disease  can  start.  It  must  be  lowered  in  some  way ; 
and  there  are  different  ways,  and  probably  ways 
of  which  we  must  be  long  ignorant.  The  lining 
of  certain  bronchi  is  markedly  susceptible.  Here 
the  resistance  may  be  diminished  by  an  inspired 
foreign  body  that  irritates  the  part  and  destroys 
the  cilice  that  cover  the  cell  surface,  or  by  some  other 
unknown  influence.  Then  tubercle  bacilli  are  car- 
ried to  the  point  by  the  blood-current,  or  more  likely 
by  the  inspired  air;  here  they  start  a  culture  and  pro- 
duce the  disease.  Not  one  bacillus  will  do  this.  A 
cell  or  a  patch  of  them  lowered  in  vitality  will  prob- 
ably resist  one  or  two  bacilli ;  but  presumably  there 
must  be  many  bacilli  deposited  in  such  a  spot  to  start 
a  tuberculous  lesion,  unless  the  physical  depreciation 
of  the  part  is  extreme.  Once  started,  the  process 
goes  on  for  a  length  of  time,  extends  to  other  cells, 
and  causes  numerous  minute  tubercle  nodules  long 
before  any  symptom  or  physical  sign  is  produced. 
The  lymphoid  and  epithelioid  cells  gather  about 
this  region  of  disease;  coagulation  necrosis  takes 
place,  capillaries  are  closed  off  by  inflammation  or 
thrombosis,  and  we  ha\e  the  giant-cells  with  their 
degenerate  centers  and  the  other  elements  of  the 
tubercle. 

In   reference  to   the  pathology  of  the  giant-cell 


54  Tuberculosis 

in  tuberculosis  and  other  lesions  (for  it  is  found 
in  others  —  even  in  ordinary  ulceration,  various 
non  -  tuberculous  tumors  and  irritated  parts),  the 
evidence  is  accumulating  that  this  cell  in  some  of 
its  elements  is  conservative,  and  exercises  some 
power  toward  the  destruction  of  micro-organisms. 
It  is  believed  by  some  surgeons  that  giant-cells  in 
the  midst  of  foreign  bodies  —  in  silk  ligatures  in  a 
wound  in  the  meshes  of  which  they  burrow  —  exer- 
cise a  destructive  influence  on  the  foreign  body, 
and  are  hence  beneficial.  If  such  a  power  exists, 
it  must  l)e  b}'  virtue  of  the  nuclei  in  the  periphery 
of  the  cell.  That  the  inside  of  the  cell  is  a  mass 
of  beginning  degeneration  is  probable;  and  it  is  a 
question,  from  a  pathologic  standpoint,  whether  in 
tuberculosis  the  giant-cell  is  simply  a  morbid  ele- 
ment produced  by  the  irritation  of  the  bacilli  or 
one  of  nature's  instruments  to  destroy  the  latter. 
Of  course,  reasoning  from  analogy,  we  should  be 
inclined  to  say  that  all  the  processes  of  tubercu- 
losis are  conservative  —  that  even  the  tubercle  itself, 
which  develops  around  the  bacilli,  represents  ail 
effort  of  nature  to  segregate  the  micro-organisms 
and  destroy  them.  And  while  the  giant-cell  may 
be  composed  of  nothing  but  a  few  epithelioid  and 
other  cells  with  their  persisting  nuclei  and  a  mass 
of  granular  material  in  the  center,  these  cells  may 
have  been  gathered  together  for  a  conservative  pur- 


The  Pathology  of  Tuberculosis  55 

pose,  and  it  may  be  that  the  nuclei  actually  multiply 
in  the  periphery  of  the  giant-cell  for  this  very  rea- 
son. In  this  way  we  reach  ground  where  it  is 
difficult  to  say  whether  the  action  of  this  cell  is 
conservative  or  is  altogether  morbid.  We  know 
that  the  leukocytes  in  the  blood  do  take  up  and  in 
some  degree  destroy  micro-organisms  by  the  process 
of  phagocytosis.  And  it  is  perhaps  true  that  some- 
times the  leukocytes  travel  out  from  the  blood-ves- 
sels into  cavities  or  surfaces  of  mucous  membranes, 
gather  substances  into  their  mass,  and  carry  them 
back  into  the  circulation. 

As  to  the  ingress  of  tubercle  bacilli  to  the  body, 
we  must  remember  that  the  portals  of  nature  for 
their  reception  are  mostly  the  nose  and  the  mouth. 
They  are  inspired  through  the  nose,  and  lodge  on 
the  mucous  membrane  of  its  cavities;  they  are 
swallowed  or  find  lodgement  in  the  throat,  and 
remain  there,  and  sometimes  produce  infection  of 
the  pharynx  and  tonsils  and  the  lymphatic  glands 
in  the  neighborhood.  From  the  tonsils  the  infec- 
tion may  travel  downward  through  the  lymphatics 
and  invade  a  lung  apex.  Infection  takes  place 
rarely  in  the  nose,  oftener  in  the  larynx,  occasion- 
ally in  the  trachea,  and  very  frequently  in  the 
bronchi  and  lungs.  Being  swallowed,  the  bacilli 
produce  not  infrequently  tuberculosis  in  the  ali- 
mentary canal,  particularly  if  acids  are  lacking  in 


56  Tuberculosis 

the  stomach.     They  enter  wounds  and  abrasions  of 
the  skin  and  produce  direct  infection. 

Doubtless  it  is  true  that  a  lung  tuberculosis  may 
be  produced  by  the  bacilli  being  carried  in  the 
blood-current,  but  this  I  believe  is  very  unusual. 
They  are  generally  carried  to  the  lung  by  the  in- 
spired air.  A  series  of  cases  was  studied  very  care- 
fully by  Birch  -  Hirschfeld  to  determine  the  place 
of  origin  of  lung  tuberculosis,  and  he  found  that 
nine-tenths  of  the  cases  showed  that  the  lesion  be- 
gan on  the  mucous  surface  of  the  medium-sized 
bronchi.  One  case  only  began  in  the  deep  tissue 
of  the  mucous  membrane.  This  question  is  a  very 
difficult  one  to  decide,  since  little  help  can  possibly 
be  derived  from  an  advanced  case  of  tuberculosis 
or  from  post-mortem  studies  of  the  disease.  Tu- 
berculosis begins  in  the  apex  of  the  lung  more 
often  than  in  other  portions,  and  in  the  right  side 
rather  oftener  than  in  the  left.  Theories  in  ex- 
planation of  these  facts  have  been  numerous,  one  of 
which  is  that  the  size  and  position  of  the  main 
bronchus  on  the  right  side  favor  a  deposit  of  bacilli 
in  the  right  apex.  This,  of  course,  cannot  be  true, 
since  the  large  bronchus  of  the  left  side  is  slightly 
nearer  vertical  and  is  more  inviting  to  the  deposit  of 
bacilli  than  the  right  bronchus.  Perhaps  the  right 
apex  is  more  susceptible  to  injuries  1)ecause  it  is 
nearer  the  outside  air  and  is  exposed  to  more  vicis- 


The  Pathology  of  Tuberculosis  57 

situdes.  The  air  in  passing  into  the  left  apex  goes 
down  at  an  angle  of  about  forty-five  degrees  and 
then  rises  again.  On  the  right  side  the  process  is 
only  a  little  different. 

A  study  of  the  behavior  of  inspired  dust  in  the 
different  portions  of  the  lung  throws  light  on  the 
subject.  As  a  result  of  some  careful  researches 
it  is  found  that  inspired  dust  gets  into  the  lower 
part  of  the  lung  more  readily  than  into  the  upper 
part.  This  is  what  we  should  expect.  Dust  enters 
the  base  of  the  lung  first,  then  the  middle,  and  finally 
the  upper  portion ;  it  is  eliminated  soonest  and 
most  from  the  lower  part,  and  remains  longest  in 
the  apex,  which  is  what  we  might  not  expect.  Since 
the  bacilli  are  a  part  of  the  dust,  we  see  why  the 
apex  should  furnish  the  greatest  number  of  original 
foci  of  the  disease.  But  we  do  not  know  why 
the  apices  fail  to  expel  the  dust  as  promptly  as 
other  parts  of  the  lungs. ^  This  is  a  common  ex- 
perience in  scientific  studies :  the  phenomena  that 
explain  a  condition  themselves  often  need  to  be 
explained. 

Once  the  tubercle  deposit  occurs  on  a  mucous  or 
serous  membrane,  its  products  are  easily  carried 
to  distant  regions.  I'^rom  a  focus  in  a  lung,  in- 
fecting phlegm  is  easily  carried  backward  along  the 

1  In  the  bellows  movement  of  the  lun<?  in  respiration  the 
apex  is  compressed  least  and  moves  least.  This  is  perhaps 
the   explanation   of    the   susccptil)ility. 


58  Tuberculosis 

bronchial  tubes  by  inspiration,  as  it  is  carried  for- 
ward by  coughing.  Cough  leaves  masses  of  phlegm 
lodged  at  all  points  between  the  lesion  and  the 
larynx,  ready  to  be  aspirated  back  toward  the  point 
of  origin  or  into  fresh  areas  or  into  a  region  of 
normal  lung  l)y  a  sudden  violent  inspiration.  If 
the  mucous  membrane  is  below  standard,  a  new 
focus  of  infection  may  easily  be  produced.  The 
bacilli  readily  get  into  the  circulation  by  entering 
the  lymph-current  first ;  the  glands  become  tuber- 
culous, and  fail  to  a  greater  or  less  extent  to  pre- 
vent the  entry  of  the  l)acilli  into  the  blood-current. 

In  the  pleura  and  peritoneum  it  is  easy  to  see 
how^  this  process  would  spread  when  once  started. 
In  the  peritoneum,  for  example,  a  small  focus  exists; 
adhesions  form  around  it,  so  that  it  is  segregated  — 
walled  off  from  the  rest  of  the  peritoneal  cavity  — 
but  the  peristaltic  movement  of  the  intestines  and 
the  low  vitality  of  the  adhesions  cause  them  to  be 
broken  down  easily,  and  the  infecting  substance  is 
carried  to  other  portions  of  the  peritoneum.  It 
may  extend  over  nearly  the  whole  of  the  peritoneal 
surface,  sometimes  with  positive  evidence  of  a  more 
intense  process  in  certain  portions,  as  shown  by 
greater  thickening  and  more  degeneration. 

As  to  the  pathology  of  pleuritis,  greater  difficulty 
is  encountered  than  is  the  case  in  most  other  forms 
of  tuberculosis.     Some  pathologists  insist  that  all 


The  Pathology  of  Tuberculosis  59 

cases  of  pleuritis  are  tuberculous.  At  least  many 
are  so ;  but  bacilli  are  hard  to  find  in  the  effusion, 
even  after  careful  centrifugation.  In  some  of  the 
very  cases  in  which  the  bacilli  cannot  be  found, 
injection  of  the  fluid  into  the  peritoneal  cavity  of 
a  guinea-pig  or  a  rabbit  will  produce  tuberculosis. 

It  is  an  interesting  question  why  tuberculous 
pleuritis  does  not  more  often  infect  a  lung  and 
destroy  life.  There  is  no  doubt  that  many  patients 
reco\'er  from  this  form  —  recover  completely,  live 
many  years,  and  die  of  other  diseases.  It  is  the 
rule  that  when  patients  have  had  it  they  are  pre- 
disposed to  its  recurrence,  and  not  infrequently  they 
acquire  afterward  pulmonary  tuberculosis;  but  it  is 
no  proof  that  they  are  going  to  die  of  the  pulmonary 
disease,  or  even  to  have  it.  How,  then,  does  the 
system  protect  itself  from  the  spread  of  serous  mem- 
brane tuberculosis  ? 

The  explanation  must  be  in  the  anatomy  and  phy- 
siology of  the  membranes  themselves.  They  are 
inimical  to  the  spread  of  infection  of  this  kind,  as 
they  seem  to  be  sometimes  to  the  spread  of  infec- 
tion from  pus.  These  membranes  in  health  are 
secreting  and  absorbing  fluid  all  the  time.  The 
arrangement  is  a  beautiful  one  by  which  just  a  trifle 
more  fluid  is  secreted  than  is  necessary  to  lubricate 
the  surfaces,  the  excess  being  carried  off  by  ab- 
sorption,  and  a  perfect  balance  being  maintained. 


6o  Tuberculosis 

As  soon  as  something  happens  to  poison  the  surface 
—  as  the  presence  of  tubercle  bacilli  or  other  organ- 
isms, or  some  other  irritating  thing — some  form 
or  degree  of  a  protecting  process  which  we  call 
inflammation  sets  in  and  promptly  interferes  with 
the  normal  functions  of  secretion  and  absorption; 
the  fluid  becomes  deficient  in  amount,  or  it  is  re- 
tained, fails  of  absorption,  and  effusion  results.  If 
there  is  a  great  deal  of  pain  and  some  fever  and 
painful  respiration,  we  know  we  have  that  form 
of  disorder  that  usually  goes  by  the  name  of  in- 
flammation, and  that  this  prevents  the  absorption 
of  the  fluid ;  and  if  the  fluid  accumulation  is  great, 
then  the  cavity  may  fill  rapidly  and  we  have  the 
ordinary  liquid  effusion.  If  the  fibrin-formation 
is  greater,  we  have  a  firm  deposit  that  may  become 
organized  and  cause  a  few  thin  adhesions  or  thick 
masses  that  may  cause  contraction  and  compres- 
sion of  the  lung.  If  pus  microbes  in  sufficient  num- 
bers find  their  way  into  the  cavity,  we  have  an  em- 
pyema. It  sometimes  happens  that  we  find  a  chest 
full  of  fluid — limpid,  straw-colored,  perfectly  liquid, 
not  opalescent  at  all  —  and  yet  there  has  not  been 
a  particle  of  perceptible  fever  or  pain.  The  same 
pathologic  events  occur  in  such  cases  as  do  in  all 
the  others,  only  not  in  the  same  proportion.  Prob- 
ably in  every  case  the  same  kinds  of  pathologic 
changes  take  place ;   it  is  the  variation  in  the  several 


The  Pathology  of  Tuberculosis  6i 

elements  that  leads  to  such  multifarious  symptoms. 

We  have  seen  that  fibrosis  is  a  conservative  pro- 
cess going  on  around  a  tuberculous  mass  in  the 
lung  and  extending  in  all  directions.  How  does 
it  happen  that  in  one  case  there  is  very  little  fibrosis, 
and  in  another  a  great  deal  ?  It  occurs  without  any 
relation  to  the  extent  of  tuberculosis.  Sometimes 
the  slightest  area  of  tuberculosis  —  a  mass  not  larger 
than  a  walnut  —  will  cause  a  great  dissemination  of 
fibrosis  and  an  extreme  degree  of  it.  We  can  only 
say  that  it  is  a  protecting  mo\'ement  set  up  by  the 
irritation  of  the  tuberculosis,  which  is  only  one  of 
numerous  forms  of  irritation  that  can  cause  it. 
Just  the  nature  of  it,  the  ultimate  way  of  its  hap- 
pening, nobody  knows ;  and  it  is  one  of  the  needs 
of  our  study  to  be  able  to  explain  this  phenomenon. 
Not  only  does  it  occur  as  a  conservative  process  in 
tuberculosis,  but  it  sometimes  becomes  destructive 
by  the  great  degree  of  it  in  a  lung,  disabling  the 
organ  almost  completely. 

It  is  my  belief  that  fibrosis  is  incited  to  some  de- 
gree by  the  motion  of  the  lung:  the  greater  the 
motion  and  violence  from  the  respiration,  the  great- 
er the  fibrosis ;  the  more  quiet  the  lung,  the  less 
of  this  process  —  exactly  as  the  scar-tissue  of  a 
wound  or  an  ulcer  is  increased  by  violence  and 
movement  of  the  part,  and  rapid  healing  is  helped 
by  fixation  of  the  part. 


62  Tuberculosis 

Not  only  do  we  have  fibrosis  in  this  disease,  but 
it  is  a  major  phenomenon  in  many  other  diseases 
as  well.  We  have  cirrhosis  of  the  liver,  which  con- 
sists in  a  fibrosis  of  the  connective  tissue  of  that 
organ.  We  have  cirrhosis  of  the  kidneys  in  arterio- 
fibrosis,  and  the  arterial  thickening  is  a  form  of  cir- 
rhosis, and  the  heart  enlarges  in  all  of  these  cases. 
We  do  not  know  why  this  last  event  happens.  Then 
we  have  cirrhosis  of  the  different  parts  of  the 
nerve-centers  —  of  tlie  posterior  columns,  otherwise 
tabes  dorsalis ;  cirrhosis  in  patches,  or  multilocular 
sclerosis,  which  often  extends  upward  into  the 
brain ;  and  we  have  sclerosis  of  the  brain  inde- 
pendently. ]\Iany  tumors  or  "gliomas  of  the  brain 
are  caused  in  this  way  by  a  thickening  of  the  con- 
nective tissue  of  the  organ,  and  in  spots.  It  has 
generally  been  supposed  that  paralysis  agitans  does 
not  have  an  organic  basis.  Occasionally  a  pathol- 
ogist has  discovered  post-mortem  evidence  of  thick- 
ening in  some  part  of  the  connective  tissue  of  the 
spinal  cord  or  brain,  or  of  the  nerves  perhaps ;  but 
usually  they  have  found  nothing  of  the  sort,  and 
the  lesions  named  have  been  supposed  by  some  to  be 
accidental. 

Now  by  improved  methods  of  staining  and  slic- 
ing of  nerve-tissue  it  is  proven  that  every  case  of 
paralysis  agitans  has  an  organic  basis  of  this  sort 
—  that   is,   thickening  of  connective  tissue  of  the 


The  Pathology  of  Tuberculosis  63 

brain  or  cord.  Sclerosis  of  the  skin  —  scleroderma 
is  just  as  mysterious  as  any  of  the  other  forms. 
Clearing  up  the  pathology  of  one  form  of  fibrosis 
is  very  likely  to  explain  many,  if  not  all,  of  the  other 
forms. 

If  the  phthisical  patient  lives  long  enough,  the 
lung  fibrosis  continues  to  progress  until  the  tuber- 
culosis is  entirely  healed  or  walled  in  and  has  been 
so  for  several  months.  As  long  as  it  progresses 
the  short-windedness  of  the  patient  increases  grad- 
ually. If  the  fibrosis  reaches  an  extreme  limit,  its 
contraction  destroys  many  minute  blood-vessels,  and 
so  leads  to  atrophy  of  air-vesicle  walls  and  to  in- 
creasing dyspnea,  producing  the  form  of  phthisis 
with  little  or  no  expectoration. 

I  suppose  that  a  correct  theory  of  fibrosis  of  the 
lungs  will  explain  fibrosis  about  the  joints.  We 
do  not  know  just  why  fibrosis  occurs  around  joints, 
unless  it  is  because  the  patients  have  tuberculosis; 
but  just  wliy  it  seizes  a  wrist,  a  shoulder,  an  ankle, 
or  a  knee-joint,  producing  no  ulceration,  but  some 
thickening,  pain,  and  disability,  we  do  not  know. 

The  caseous  degeneration  and  calcareous  foci  are 
products  of  destructive  changes  from  poverty  of 
nutrition  in  the  part.  A  particular  kind  of  nutri- 
tional depreciation  seems  to  be  required  in  order 
to  produce  cheesy  degeneration.  Cut  off  the  blood- 
supply  from  a  part  of  the  lung  suddenly,  and  it  will 


64  Tuberculosis 

break  down  in  degeneration,  but  not  the  cheesy 
form ;  it  will  be  a  slough,  and  will  produce  in  the 
breath  of  the  individual  the  aromatic  fetor  of  gan- 
grene. But  these  masses  that  undergo  cheesy  de- 
generation have  had  their  nutrition  cut  off  in  a 
more  gradual  way,  and  very  likely  some  other  in- 
fluence besides  this  lessening  of  nutrition  plays  a 
part  in  the  process  —  as,  for  example,  the  peculiar 
character  of  infection ;  but  I  believe  that  the  rate  of 
reduction  in  nutrition  plays  as  important  a  part. 
The  calcification  from  union  of  cheesy  matter  and 
lime-salts  is  identical  with  the  incrustations  that 
form  around  foreign  bodies,  as  ligatures  and  other 
objects,  sometimes  imbedded  in  the  body. 

Sometimes  a  tuberculous  mass  becomes  encap- 
sulated ;  fibrous  tissue  surrounds  it,  and  it  remains 
in  the  part  as  a  foreign  body,  the  patient,  perhaps, 
being  supposed  to  be  cured.  So  long  as  the  mass 
is  surrounded  by  a  thick  layer  of  fibrous  tissue,  it 
is  harmless  to  the  system;  but  a  little  rough  hand- 
ling or  a  lowering  of  vitality  of  the  periphery  may 
easily  lead  to  a  breaking  down  of  its  protecting 
walls  and  to  some  of  its  substance  being  absorbed, 
and  a  quick  miliary  infection  taking  place. 

It  is  possible  for  a  person  to  die  of  tuberculosis 
without  a  single  tubercle  having  been  formed.  Such 
cases  are  exceedingly  rare  —  in  fact,  occur  chiefly 
in  experimental  tuberculosis  —  and   they  illustrate 


The  Pathology  of  Tuberculosis  65 

how  death  may  result  from  the  influence  of  enor- 
mous swarms  of  bacilli,  and  before  the  reaction  of 
the  tissues  that  usually  produces  tubercles  can  take 
place. 

As  tuberculosis  spreads  through  a  lung,  catarrhal 
pneumonia  may  occur  here  and  there  within  the 
area  of  its  presence,  and  the  alveoli  of  the  lung 
become  filled  with  debris,  epithelium,  red  blood- 
corpuscles,  leukocytes,  and  bacilli.  Sometimes  the 
lung  breaks  down  in  these  regions  —  prol^ably  inside 
the  ring  of  pneumonia — and  numerous  little  cavities 
form,  or  a  single  large  one.  The  pneumonia  has- 
tens the  breaking  down  of  the  tuberculous  mass. 
This  pneumonia  frequently  clears  up  and  sometimes 
in  a  most  surprising  manner,  the  lung  casting  off 
its  products  as  it  does  those  of  an  ordinary  pure 
lobar  pneumonia. 

Miliary  tuberculosis  is  a  form  that  occasionally 
invades  a  large  mass  of  an  organ,  a  whole  lung  or 
both  lungs,  tubercles  developing  throughout  the 
mass  or  in  many  parts  of  the  body  at  once.  Some- 
times in  one  or  both  lungs  this  form  may  exist 
for  a  long  time  without  either  l)reaking  down  in 
cavities  or  leading  to  mixed  infection  and  high 
fever.  Such  cases  simply  differ  from  those  just 
spoken  of,  in  which  a  great  dose  of  tuberculous 
poison  rapidly  saturates  the  system,  in  the  fact  that 
there  is  in  these  cases  just  enough  reacting  power  in 
■5 


66  Tuberculosis 

the  tissues  to  produce  tubercles.  Fever,  usually 
moderate  in  degree,  is  produced  by  the  growth  and 
presence  of  these  bodies  in  miliary  invasion,  by  in- 
flammation, and  probably  also  by  the  poisoning- 
arising  from  the  products  of  the  bacilli.  We  have 
found  that  a  minute  dose  of  tuberculin  nearly  always 
produces  fever  in  a  body  infected  with  tuberculosis; 
but  a  large  dose  may  produce  fever  in  a  person 
not  so  infected.  We  must  believe,  then,  that  the 
poison  of  miliary  invasion  is  able  to  produce  some 
fe\er  without  mixed  infection.  In  some  cases  of 
miliary  tuberculosis  the  patient  is  overpowered  in 
a  few  days;  but  in  other  cases  he  improves,  and 
we  have  what  may  be  called  chronic  miliary  tubercu- 
losis. This  may  last  a  long  time  and  produce  little 
fever,  cough,  or  expectoration,  but  may  cause  great 
weakness  and  extreme  shortness  of  breath. 

It  is  a  question  much  studied  how  the  tubercle 
bacilli  are  carried  from  a  particular  focus  to  distant 
parts  of  the  body;  and  I  think  we  are  justified  in 
believing  that  there  are  two  main  avenues  of  dis- 
tribution —  namely,  the  blood-vessels  and  the  lym- 
phatics. But  the  lymphatics  can  only  in  a  large  way 
carry  the  bacilli  centripetally,  while  the  blood-ves- 
sels eventually  carry  them  centrifugally  and  every- 
where. 

As  to  the  ultimate  pathology  of  the  cachexia,  we 
arc  perhaps  no  wiser  than  we  are  regarding  that 


The  Pathology  of  Tuberculosis  67 

of  fibrosis.  Our  theories  of  to-day  are  likely  to 
be  changed  to-morrow,  l)ut  we  know  in  a  general 
way  that  tuberculous  cachexia  must  be  in  some 
way  produced  by  the  surcharging  of  the  system 
with  poisons  of  various  sorts  caused  directly  or 
indirectly  by  the  disease.  It  is  impossible  for  the 
body  to  get  rid  of  them.  They  reduce  the  capacity 
for  nutrition  and  demoralize  the  blood-making 
power  and  probably  in  a  similar  ratio  deprave  and 
impede  the  excretory  functions. 

Probably  the  cachexia  of  tuberculosis  does  not 
differ  essentially  from  that  due  to  other  diseases, 
although  it  may  differ.  The  red  corpuscles  are 
reduced  in  number;  the  whites  vary  greatly  in  dif- 
ferent forms  of  cachexia,  as  they  are  presumably 
called  on  by  the  physiologic  forces  in  varying  de- 
grees for  the  destruction  of  pathogenic  micro-organ- 
isms, and  perhaps  for  the  manufacture  of  antitoxins. 
Manifestly,  no  new  and  unusual  demand  can  Ije 
made  on  the  physiologic  forces,  whether  it  be  toward 
destruction  of  the  enemies  of  the  body  or  toward 
repair  of  its  injuries,  without  tending  to  throw  them 
out  of  balance.  And  when  the  demand  is  too  heavy, 
the  balance  is  not  recovered.  Cachexia  ensues  then, 
and  perhaps  death. 

The  evidence  is  conclusive  not  only  that  the  leu- 
kocytes in  the  blood  may  exercise  a  power  inimical 
to  the   bacilli,   but  that  there  is   developed   in  the 


68  Tuberculosis 

blood-serum  also  a  true  antitoxin,  a  substance  that 
is  to  some  degree  destructive  of  the  bacilli.  It  is 
even  demonstrated  that  the  Widal  reaction  of  ag- 
glutination of  tubercle  bacilli  in  pure  culture  is 
sometimes  producible  by  the  blood-serum  of  tuber- 
culous patients. 


CHAPTER  V 

THE   ETIOLOGY   OF  TUBERCULOSIS 

The  question  of  how  people  get  tuberculosis  is 
immensely  important,  since  it  leads  to  the  subject  of 
prophylaxis,  which  is  the  most  important  of  all. 
We  have  already  seen  that  the  bacilli  are  carried 
into  the  body  largely  by  the  air,  and  that  all  people, 
especially  those  who  live  in  cities,  inspire  them 
repeatedly  and  in  varying  numbers.  We  know  also 
that  there  must  be  some  power  residing  in  the  body 
that  resists  them  as  it  does  other  micro-organisms; 
otherwise  everybody  would  acquire  the  disease. 

The  bacilli  grow  in  a  good  culture-medium  wher- 
ever it  may  be,  and  they  find  one  often  in  the 
human  body.  Perfectly  normal  animal  tissue  re- 
sists them  in  varying  degrees;  there  must  be,  there- 
fore, a  weak  spot  in  the  body  —  one  weakened  by 
some  local  condition  or  extraneous  influence,  or 
weak  congenitally  —  to  make  is  possible  for  the  dis- 
ease to  start.  Many  tissues  are  able  to  resist  a 
few  bacilli,  while  they  arc  powerless  against  a  swarm 
of  them. 

Frequently  a  large  number  of  bacilli  are  required 
to  start  a  culture  in  the  body.  Some  writers  on 
the  subject  have  exen  gone  so  far  as  to  place  the 
number  at  a  dozen  or,  two. 

69 


70  Tuberculosis 

Animal  bodies  differ  in  their  resisting  power. 
The  various  species  differ,  and  different  individuals 
of  the  same  species  show  a  varying  resistance  to 
the  disease,  depending  on  manifold  circumstances. 
The  several  tissues  and  organs  of  the  body  differ 
in  their  susceptibility.  Human  beings  are  subject 
to  the  same  laws.  The  susceptibility  is  both  con- 
genital and  acquired.  The  children  of  people  who 
have  had  tuberculosis  are  more  likely  than  others 
to  take  the  disease.  The  very  fact  of  his  parents 
having  had  the  disease  presumes  a  reduced  power 
to  resist  it  on  the  part  of  any  individual.  It  pre- 
sumes, but  does  not  prove. 

The  resisting  power  to  this  disease  is  not,  con- 
trary to  the  generally  accepted  notion,  identical 
with  ordinary  physical  vigor.  The  common  belief 
among  lay  people  is  that  a  physically  strong  person 
will  resist  tuberculosis,  while  a  weaker  one  will  ac- 
quire it.  This  is  in  general  untrue.  The  athletic 
people  have  by  their  strength  no  protection  against 
tuberculosis.  Of  course,  this  is  no  warrant  for 
any  one  to  permit  his  vigor  to  fall  below  his  normal 
standard.  The  best  resistance  for  each  person  is 
in  his  normal  vigor  and  development.  Therefore 
athletic  exercise,  which  is  so  generally  invoked  as 
a  preventive,  is  often  misused,  and  often  produces 
an  opposite  effect.  Muscular  vigor  is  no  refuge 
against    tuberculosis.      Athletes    acquire    it    rather 


The  Etiology  of  Tuberculosis  71 

more  readily  than  thin,  weakly  people  with  spare 
musculature  but  normal  organic  vigor.  And  I 
have  seen  many  people  die  of  tuberculosis  who,  I 
believe,  might  have  lived  had  they  not  attempted 
to  recover  by  becoming  athletes.  This  is  not  to 
say  that  it  is  a  good  thing  to  be  debilitated.  It  is 
good  to  have  the  system  up  to  its  normal  vigor ;  but 
athletic  vigor  too  often  consists  in  an  increase  of 
muscular  power  without  a  proper  balance  of  the 
several  physiologic  forces  necessary  to  ensure  proof 
against  pathogenic  microbes. 

Tuberculosis  rarely  goes  directly  from  the  mother 
to  the  child.  There  are  a  few  instances  on  record 
of  animals  acquiring  it  in  ntcro;  so  that  it  cannot 
be  said  that  bacilli  never  travel  from  the  mother 
to  the  child.  But  for  all  purposes  of  practical  study 
and  management  we  may  assume  that  the  disease 
is  always  acquired  from  without,  by  bacilli  taken 
in  from  the  atmosphere  or  with  food  or  drink. 

Of  the  influences  that  invite  tuberculosis  to  an 
individual,  lowered  vitality  is  one  of  the  most  im- 
portant —  lowered  vitality  produced  by  various  dis- 
turbances of  function.  In  our  divisions  of  labor, 
in  our  occupations  that  confine  us  to  certain  attitudes 
and  certain  lines  of  work  that  are  unvarying,  and 
in  our  lives  that  are  monotonous,  our  physical  forces 
are  not  kept  balanced ;  we  exercise  too  much  in 
one  direction  and  too  little  in  another,  and  throw 


72  Tnljerculosis 

the  functions  out  of  balance,  and  so  lower  the  vital- 
ity of  the  whole  system.  Thus  we  increase  our  sus- 
ceptibility to  the  disease. 

There  is  no  question  that  bad  air  is  one  of  the 
forces  that  induce  tuberculosis,  and  people  every- 
where breathe  bad  air  a  great  deal  of  the  time.  We 
breathe  indoor  air  most  of  the  time,  we  are  indoors 
on  an  average  more  than  half  of  all  the  hours,  and 
we  never  provide  —  and  usually  cannot  provide  — 
in  our  working  and  sleeping  places  an  atmosphere 
as  good  as  the  outdoor  air.  This  influence  invites 
tuberculosis  by  lowering  the  vitality  of  the  system 
as  a  whole,  and  by  the  injury  it  inflicts  upon  cer- 
tain organs. 

Then,  starvation  brought  about  in  one  way  or 
another  produces  tuberculosis.  Experiments  with 
animals  have  proved  this.  You  can  introduce  into 
the  tissues  a  large  number  of  bacilli,  and  if  the 
animals  are  kept  properly  nourished  a>id  under  con- 
ditions of  good  hygiene,  they  will  escape  the  dis- 
ease; whereas  they  succumb  promptly  when  starved 
or  under  bad  conditions.  Many  persons  undergo 
a  sort  of  star\-ation  in  numerous  ways, —  not  always 
by  lack  of  food,  often  by  disturbances  of  digestion 
and  assimilation.  The  result  is  exactly  as  with 
animals:  they  are  rendered  susceptible  to  the  dis- 
ease. Sometimes  the  tissues  are  partially  starved, 
and  poisoned  even  when  a  large  amount  of  food  is 


The  Etiology  of  Tuberculosis  73 

taken  regularly :  the  assimilation  is  poor  and  the 
depuration  bad. 

Mental  worry  and  discouragement  lower  vitality 
and  so  invite  the  disease.  A  class  of  people  who 
receive  ten  per  cent,  less  wages  than  another  class 
doing  identical  work  will  show  a  larger  proportion 
of  tuberculosis,  even  when  they  have  the  same  qual- 
ity and  amount  of  food  as  those  with  the  higher 
wages,  and  when  the  physical  stamina  of  the  two 
classes  is  substantially  identical. 

Over-stimulation  plays  a  part  in  causation.  In 
our  intense  lives  we  can  hardly  avoid  overstimulat- 
ing,  in  some  direction,  at  some  time.  If  it  is  not 
alcohol,  it  is  coffee  or  tea,  or  some  article  of  diet, 
or  it  is  tobacco  —  if  this  is  really  a  stimulaiit.  These 
non-food  articles  are,  sometimes  at  least,  poisons 
to  the  brain,  and  they  may  disturb  assimilation  and 
balance,  and  so  lower  the  vitality.  Excesses  in 
child-bearing  and  in  the  indulgence  of  passions  are 
strains  upon  the  system  and  lower  its  resistance  to 
tuberculosis. 

The  vitality  of  the  system  may  be  lowered  by 
disease,  and  so  tuberculosis  ensue.  Here,  in  addi- 
tion to  the  reduced  vigor,  we  have  some  possible 
secondary  effect  of  tlie  microl)es  which  caused  the 
preceding  disea.se.  Typhoid  fever,  measles,  Ijron- 
chitis,  and  whooping  cough  are  not  infref|uently 
followed  by  tuberculosis.     Sex  seems  to  have  little 


74  Tuberculosis 

influence  on  the  acquisition  of  the  disease.  Age  has 
a  good  deal  of  influence.  Children  often  recover 
from  tuberculosis  of  the  glands,  and  sometimes  even 
when  the  lungs  are  involved.  They  are  able  to 
resist,  probably  because  they  are  growing  and  devel- 
oping. In  the  years  of  adolescence  the  resisting 
power  to  tuberculosis  seems  to  be  less.  The  body 
has  perhaps  attained  its  growth,  but  the  tissues  and 
powers  are  still  unhardened,  and  the  system  goes 
down  rapidly  under  the  disease.  The  best  hope  of 
recovery  is  untler  twelve  or  over  twenty-five  years 
of  age.  From  twenty-five  to  fifty-five  are  probably 
the  most  resisting  years  of  life. 

The  resistance  shown  by  the  growing  body  is 
illustrated  in  pregnancy.  A  woman  with  tubercu- 
losis of  the  lungs  that  is  making  rapid  progress, 
becoming  pregnant,  may  go  through  this  period 
and  the  disease  seem  to  stop;  it  often  does  stop 
its  progress.  Her  resisting  power  has  been  aroused 
by  the  increased  and  changed  physiologic  movement 
of  the  body  due  to  the  new  condition.  These  patients 
often  go  down  to  death  speedily  after  confinement. 

The  belief  is  current  among  the  laity  that  or- 
dinary simple  catarrh  of  the  nasal  passages  and 
pharynx  is  likely  t(^  lead  to  tuberculosis  of  the  lungs 
by  some  process  of  traveling  downward.  But  this, 
theory  is  wholly  groundless.  These  forms  of  ca- 
tarrh not  only  ne\-er  produce  tuberculosis,  but  they 


The  Etiology  of  Tuberculosis  75 

do  no  harm  of  any  sort  except  to  the  convenience 
of  the  patient.  So  far  from  causing  this  disease, 
catarrh  is  likely  to  protect  the  tissues  from  contact 
of  the  bacilli.  The  catarrh  in  certain  cases  is  prob- 
ably a  consequence  of  physical  debility,  which  itself 
always  invites  tuberculosis;  but  it  never  travels 
downward  to  produce  the  disease. 

Nationality  has  some  influence  on  susceptibility 
to  tuberculosis.  The  Jewish  people  have  very  little 
of  it ;  on  the  other  hand,  Americans  and  Irish  have 
it  in  large  proportion,  and  the  negro  in  America  is 
very  susceptible. 

Climate  exercises  little  or  no  protective  influence 
over  the  individual  against  the  acquisition  of  tuber- 
culosis. Such  a  statement  will  strike  many  as  sur- 
prising; but  it  is  true.  In  Colorado,  New  IMexico, 
Arizona,  and  Southern  California,  places  where  in- 
valids are  sent  in  great  numbers  to  recover  from  the 
disease,  and  where  they  often  do  recover,  people 
acquire  it  initially  and  from  the  same  causes  as 
in  other  climates.  Those  climates  are  not  pro- 
tective per  sc,  although  they  may  be  slightly  so  by 
the  outdoor  life  they  make  possible.  Of  course,  the 
resistance  is  greatest  where  the  climatic  worries  are 
least.  Altitude,  that  has  been  supposed  to  exercise 
such  a  power  over  tuberculosis,  has  none  to  prevent 
a  person  from  taking  it.  Dryness  of  atmosphere 
probably  has  no  protecting  influence,  whatever  its 


76  Tuberculosis 

therapeutic  power  may  l^e.  Regions  of  great  sun- 
shine and  atmospheric  chathermancy  show  a  small 
proportion  of  acquired  cases;  but  this  is  probably 
due  less  to  any  inlTuence  on  human  susceptibihty 
than  to  tlie  greater  destruction  of  the  bacilli  in  the 
air  l)y  the  sun's  rays.       ' 

We  accjuire  the  disease  mostly  through  the  air, 
but  also  through  food  and  drink,  as  well  as  by  direct 
contact.  The  bacilli  are  taken  into  the  lungs  direct; 
they  lodge  in  the  mouth  and  throat  and  are  swal- 
lowed. Thence  they  enter  the  mesenteric  glands 
and  get  into  the  blood.  They  also  enter  the  tonsils 
and  pass  into  the  cervical  glands  and  probably  the 
lungs. 

We  acf|uire  the  disease  mostly,  perliaps  wholly, 
from  human  sources ;  possibly  sometimes  we  get 
it  from  animal  sources,  as  from  milk,  yet  the  evi- 
dence is  increasing  that  bovine  tuberculosis  must 
be  very  rarely  transmitted  to  man.  Sour  milk  is 
quite  as  cai)al)le  of  carrving  the  germs  as  sweet 
milk.  Rarely  do  wc  acfjuire  live  bacilli  fn^m  meat, 
because  meat  for  food  is  nearly  always  cooked.  It 
is  found  that  one  per  cent,  of  tubercnlous  cows 
have  the  disease  in  the  udder.  The  milk  of  infected 
cows  with  n()n-tul)ercul()us  udders  contains  bacilli 
in  50  per  cent,  of  cases.  So  there  is  no  lack  of 
bovine  bacilli  in  the  milk  served  l)y  careless  or  un- 
scrupulous dairymen. 


The  Etiology  of  Tuberculosis  'jy 

It  is  almost  impossible  to  produce  tuberculosis 
in  cattle,  pigs,  sheep,  and  goats  "by  inoculation,  in- 
halation, and  feeding  with  the  products  of  human 
tuberculosis;  while  they  are  easily  infected  and  die 
speedily  from  those  of  the  bovine  disease.  Accord- 
ing to  Koch,  this  argues  the  improbability  of  the 
transmission  of  the  disease  to  man  from  the  flesh 
and  milk  of  cattle.  If  it  could  occur  easily,  the 
number  of  cases  of  the  primary  disease  of  the  intes- 
tines among  children,  who  sul)sist  largely  on  cow's 
milk,  ought  to  be  much  greater  than  it  is.  As  a 
matter  of  fact,  this  form  of  the  disease  is  extremely 
rare.  Of  933  cases  of  tul^erculosis  among  children 
in  hospitals  in  Berlin,  no  case  of  tu1)erculosis  of  the 
intestines  was  found  except  in  conjunction  with 
disease  of  the  lungs  and  bronchial  glands  (Bagin- 
sky).  Biedert  found  but  16  cases  of  primary  intes- 
tinal tuberculosis  in  3104  autopsies  on  tuberculous 
children,  or  51-100  of  one  [)er  cent.  And  Koch 
has  seen  but  2  cases  of  primary  tuljerculosis  of  the 
intestines  post-mortem. 

It  is  certain  that  the  disease  is  distributed  \)y 
the  sputum  becoming  dry  and  being  ground  into 
powder,  thus  forming  a  part  of  the  dust  of  the 
air  and  scattering  tlic  bacilli  widely.  We  get  them 
not  only  in  the  streets,  but  in  the  dust  of  our 
houses.  Even  when  every  effort  is  made  to  destroy 
the   sputum   of    patients,   a   violent   and   explosive 


78  Tuberculosis 

cough  will  frequently  expel  small  particles  which 
may  alight  on  carpets,  hangings,  furniture,  clothes, 
and  beards,  and  so  get  into  the  air.  Patients  often 
expectorate  into  their  handkerchiefs;  these  becoiVie 
dry,  and  when  crushed  and  handled  they  likewise 
distribute  the  bacilli. 

Animal  bacilli  are  more  virulent  than  those  from 
human  beings.  Old  cultures  that  have  been  kept  for 
a  long  time  in  test-tubes  and  propagated  from  time 
to  time  lose  their  virulence.  It  is  said  that  the 
orio'inal   stock   of  bacilli   of   Professor  Koch,   that 

o 

has  been  kept  alive  by  repeated  cultivation,  has 
become  non-virulent.  On  the  other  hand,  if  you 
take  a  slightly  virulent  culture  and  inoculate  an 
animal  with  it,  from  this  animal  another  one,  and 
so  on,  the  virulence  will  increase  until  the  highest 
point  of  intensity  is  reached. 


CHAPTER  VI 
THE  SYMPTOMS  OF  TUBERCULOSIS 

The  symptoms  of  tuberculosis  do  not  appear  at 
the  beginning  of  the  disease.  That  is  one  of  the 
misfortunes  of  the  study  and  treatment  of  it.  The 
bacilh  grow,  spread,  and  burrow  for  a  time  before 
symptoms  or  signs  appear.  The  disease  begins  the 
moment  a  few  bacihi  find  a  good  culture-medium 
in  the  body  and  commence  to  multiply.  They 
spread,  perhaps  with  the  aid  of  leukocytes  that  move 
in  most  unexpected  ways;  they  burrow  into  the 
tissues  by  their  multiplication,  and  around  them 
the  minute  tubercles  develop.  This  goes  on  pro- 
gressi\ely  until  one  of  two  or  three  things  oc- 
curs :  either  the  appearances  are  changed  and  so 
signs  appear,  as  in  local  or  surface  tuberculosis,  of 
which  lupus  and  anatomic  tubercle  are  examples;  or 
there  is  an  organic  change  and  functions  become 
disturbed ;  or  there  is  lowered  vitality  from  sys- 
temic poisoning  —  or  all  three  together.  The  pa- 
tient does  not  realize  it  until  the  appearances  change 
or  the  functions  are  altered  —  the  functions  of  the 
part  or  of  some  other  ]5art  dependent  upon  it  — 
or  until  some  new  function  appears,  such  as  cough, 
or  some  calamity  like  a  hemorrhage. 

79 


8o  Tuberculosis 

Therefore,  in  lung  tuberculosis  we  are  obliged 
to  wait  for  evidence  until  the  function  of  the  part 
is  disturbed,  as  in  some  impairment  of  the  breathing, 
or  until  some  effect  is  produced  on  the  system  that 
lowers  its  vigor  or  impairs  other  functions.  And 
often  the  first  symptom  that  appears  belongs  to  the 
third  category,  that  of  infection,  and  consists  of 
reduced  vigor,  or  fever,  or  both.  In  a  great  num- 
ber of  cases  the  first  symptom  the  patient  can  tell 
about  is  lowered  vitality.  In  some  of  the  lung 
cases  cough  or  hemorrhage,  or  both,  occur  nearly 
as  early.  Lowered  vitality  is  expressed  by  loss  of 
weight,  strength,  and  appetite.  At  the  same  time 
the  digestion  becomes  poor,  and  the  patient  may 
complain  of  gastric  discomfort  and  diarrhea  or 
constipation. 

The  body  is  infected  with  the  poison  of  the  dis- 
ease, and  perhaps  with  pus  i)roducts,  or  wholly  by 
the  latter.  By  the  time  the  i)us  infection  is  at  all 
marked,  cough  occurs  and  is  often  vexatious,  and 
daily  fever  as  well,  perhaps  with  chills  at  the  begin- 
ning and  perspiration  at  the  end.  We  not  only  have 
these  changes  of  function,  but  we  have  cough,  which 
can  hardly  be  said  to  be  a  change  of  function. 
Rather  it  is  one  of  nature's  reserve  functions,  whose 
purpose  is  to  relieve  the  respiratory  passages  of 
offensive  materials ;  and  it  often  tries  blindly  to  brush 
away  irritations,  which  it  is  powerless- to  affect. 


The  Symptoms  of  Tuberculosis  8i 

Discomfort  in  a  lung  is  a  most  unusual  thing. 
The  patient  is  uncomfortable  because  he  has  a  cough, 
or  possibly  some  pain  in  the  chest-wall.  Perhaps 
he  expectorates  phlegm,  sometimes  even  a  little 
blood,  and  that  alarms  him;  but  pain,  if  he  has  it 
—  and  he  often  has  —  is  not  in  the  lung.  It  is 
always  in  either  the  walls  of  the  chest  or  the  pleura, 
or  both.  He  will  declare  that  his  lung  is  sore ;  but 
we  know  that  he  is  mistaken,  and  that  the  pain  is 
outside  that  organ. 

The  elevation  of  temperature  will  be  recognized 
as  an  evidence  of  infection,  and  usually  mixed  infec- 
tion. It  has  wide  variations  in  degree,  and  if  the 
pus  infection  is  considerable,  the  fever  is  liable  to 
rise  rapidly  and  to  be  announced  by  a  chill,  which 
occurs  early  in  the  day.  At  first  it  is  not  a  pro- 
nounced chill,  but  a  slight  chilly  sensation  that  is 
followed  or  attended  by  fever.  The  temperature  is 
highest  in  the  afternoon  and  evening,  and  as  it  falls 
the  patient  may  perspire  a  variable  amount.  When 
this  condition  has  been  reached  the  vitality  is  often 
much  reduced,  the  power  of  the  body  drops,  the 
patient  is  losing  weight,  his  digestion  is  impaired, 
and  he  begins  to  actphre  tliat  condition  known  as  ca- 
chexia. If  the  temperature  rises  swiftly  at  any  time, 
it  is  proof  of  pus  infection  to  a  consideral)le  degree. 
If  there  is  a  rapid  rise  of  temperature,  there  is  likely 
to  be  relatively  more  profound  chills.     Then,  too, 

6 


82  Tuberculosis 

the  temperature  is  most  likely  to  drop  quickly  and 
with  profuse  perspiration.  This  is  the  colliquative 
sweat  of  phthisis. 

Now  these  symptoms,  which  are  the  general  ones 
of  the  disease,  come  in  a  thousand  different  ways 
and  in  as  many  different  proportions,  so  that  no 
two  patients  present  the  same  clinical  picture.  One 
patient  coughs  more  than  another;  one  has  more 
fibrous  tissue  that  protects  the  diseased  parts;  one 
gets  sick  faster  than  another.  As  a  consequence 
of  personal  idiosyncrasy,  the  irritation  in  the  bron- 
chial tubes  or  in  the  trachea  is  most  variable. 
Hence  some  victims  cough  violently  or  excessively, 
and  others  very  little.  Some  patients  with  tuber- 
culosis have  great  quantities  of  pus  in  the  breath 
channels  and  the  most  remarkable  rales  of  all  kinds, 
and  yet  hardly  cough  at  all.  Others  cough  on  the 
slightest  provocation ;  and  they  cough  violently  to 
raise  particles  of  phlegm  no  larger  than  the  head 
of  a  pin ;  they  e\'en  cough  from  irritation  w^hen 
there  is  no  phlegm  to  raise.  In  general  these  pa- 
tients resist  cough  by  taking  shallow  breaths.  It 
is  a  significant  symptom  of  the  disease  if  the  patient 
coughs  on  taking  a  deep  inspiration ;  for  then  one 
may  know^  that  there  is  some  phlegm  in  the  bron- 
chial tubes,  probably  the  smaller  ones,  and  that 
the  inspiration  has  drawn  some  of  it  peripherally 
into   still   more   minute   tubes   whose  mucous   sur- 


The  Symptoms  of  Tuberculosis  83 

face  is  more  normal,  and  so  produced  the  cough. 

jMost  of  the  phlegm  that  these  patients  raise  is 
mucus  even  when  it  looks  very  purulent.  The 
amount  of  pus  is,  as  a  rule,  relatively  small.  Case- 
ous matter  is  seldom  brought  up,  and  still  less  often 
small  particles  of  calcareous  matter.  The  propor- 
tion of  pus  and  mucus  varies  widely  at  different 
times  and  under  different  circumstances.  Blood  is 
occasionally  present  in  the  expectoration,  and  in 
varying  amount,  from  a  mere  streak  of  color  to 
almost  pure  blood  in  great  quantities.  It  should 
not  disturb  the  mind  of  any  patient  if  the  amount 
is  small,  for  slight  bleedings  are  useful. 

The  patient  nearly  always  coughs  more  or  less  if 
the  tuberculosis  begins  proximally  to  the  outer  sur- 
face of  the  lung  —  that  is,  if  the  bronchi  are  irri- 
tated and  if  there  are  unoccluded  air-vesicles  and 
bronchioles  situated  distally  to  the  lesion.  If  one 
lung  is  solely  or  chiefly  affected,  and  the  lesion  has 
not  reached  the  surface  of  it,  the  patient  always 
coughs  more  when  he  lies  on  the  affected  side. 
This  is  for  the  same  reason  that  a  deep  inspiration 
causes  cough  —  namely,  that  the  phlegm  flows  from 
larger  and  diseased  tubes  into  smaller  and  healthy 
ones.  Tills  always  sets  up  coughing.  In  lying  on 
the  affected  side,  gravity  favors  this  phenomenon. 

Let  a  patient  have  tuberculosis  in  the  most  com- 
mon point  —  near  the  center  of  the  apex  of  a  lung, 


84  Tuberculosis 

with  some  unaffected  l)ronclii  peripherally  to  it. 
Fluid  will  appear  in  the  bronchi  of  the  part,  and 
if  the  patient  lies  on  the  diseased  side,  the  fluid 
\y\\\  by  its  weight  tend  to  flow  downward  into  the 
smaller  tubes ;  it  will  pass  into  tubes  that  are  healthy, 
set  up  an  irritation,  and  produce  rales  and  cough. 
Let  the  patient  now  turn  on  the  other  side,  and 
the  cough  will  cease,  because  the  affected  region  is 
uppermost  and  the  phlegm,  in  flowing  downward, 
traverses  enlarging  tubes  and  finds  less  and  less 
obstruction.  The  mucus  will  stick  to  the  lining  of 
the  larger  bronchi  and  trachea,  w'ill  lose  by  evapora- 
tion some  of  its  moisture,  and  so,  being  more  con- 
centrated, may  remain  for  many  hours.  In  this  way 
a  patient  will  often  retain  his  phlegm  for  a  whole 
night;  but  wdien  he  gets  up  and  takes  food  and 
drink,  more  fluid  soon  appears  on  the  lining  of  the 
tubes  —  oozes  from  the  mucous  membrane ;  this 
loosens  the  retained  expectoration,  which  is  set  in 
motion  by  the  air-currents  and  so  causes  rales  or 
rhonchi ;  it  flows  down  into  smaller  tubes ;  then 
the  patient  begins  to  cough  and  expectorate.  He 
may  expel  all  the  products  of  a  night  in  a  few 
minutes.  A  i)atient  will  frequently  cough  almost 
incessantly  during  the  night  if  he  is  obliged  to  lie 
on  the  affected  side,  while  if  he  lies  on  the  sound 
side  he  may  pass  the  night  in  quiet  sleep. 


The  Symptoms  of  Tuberculosis  85 

This  symptom^  ceases  if,  and  when,  the  lesion 
extends  to  the  distal  portions  of  the  lung,  and  all 
the  air-spaces  are  filled  with  the  products  of  the 
disease.  Then  there  is  no  normal  bronchial  mu- 
cous surface  to  be  irritated  by  the  encroachment 
of  morbid  matter;  there  is  no  air  beyond  the  limits 
of  the  lesion  to  be  utilized  to  move  phlegm,  and  so 
there  is  no  cough  from  irritation  in  that  quarter. 

The  vitality  of  these  patients  is  often  lowered 
by  their  failure  to  get  sufficient  sleep,  because  of 
nagging  cough  in  the  night.  And  the  act  of  cough- 
ing is  often  harmful,  since  it  may  cause  fatigue, 
and  more  or  less  violence  to  the  diseased  tissues, 
thereby  increasing  fibrosis.  The  cough  is  to  be  en- 
couraged when  it  l)rings  up  phlegm,  but  it  should 
be  restricted  to  the  gentlest  efforts  that  will  accom- 
plish this  purpose.  The  cough  often  tires  the  chest- 
muscles,  but  it  does  not  otherwise  hurt  the  system 
as  a  whole,  and  it  rarely  injures  the  larynx.  But 
when  it  keeps  the  patient  awake  it  is  a  misfortune; 
and  when  the  cough  is  racking  and  harassing,  as 
when  no  phlegm  or  very  little  is  brought  up,  it 
sometimes  provokes  a  hemorrhage,  l)ut  rarely  a  large 
one,  for  the  large  ones  only  follow  extreme  invasion 
of  the  vessel   walls  by  the  tuljcrculosis ;    and  that 

'For  a  fuller  account  of  this  "symptom,"  see  a  paper  by 
the  author,  entitled,  "Cough  Induced  by  Posture  as  a  Symp- 
tom Nearly  Diagnostic  f)f  Phthisis,"  where  (so  far  as  he 
knows)  it  was  first  described,  'rransactions  of  tlie  Association 
of  American  Physicians,   1894,  vol.   ix,  p.  229. 


86  Tuberculosis 

event  produces  large  hemorrhages  with  or  without 
cough. 

Indigestion  of  various  forms  and  degrees  is  a 
symptom  of  pulmonary  tul)erculosis,  particularly 
where  there  is  fever.  As  a  result  of  the  fever  there 
is  anorexia;  most  of  the  patients  eat  little,  and 
they  eat  in  a  most  erratic  manner.  They  do  not 
know  how  to  eat ;  that  is,  they  devour  the  things 
they  like  best,  which  are  usually  the  foods  that  are 
least  nourishing  and  digestible.  They  will  take 
fruit  that  is  appetizing,  but  little  nourishing,  and 
refuse  foods  that  make  tissue;  and  they  eat  at  times 
and  in  quantity  as  their  whims  move  them.  Left 
to  themselves,  they  rarely  eat  more  than  three  times 
a  day,  usually  two  \-ery  slight  meals,  and  one  rather 
hearty  meal  which  is  never  perfectly  digested.  In 
this  way  their  digestion  is  disturbed  and  they  have 
gastric  discomfort,  acidity,  water-brash,  occasional 
vomiting,  and  very  often  diarrhea.  Sometimes  this 
last  is  due  to  tuljerculosis  of  the  intestine.  Some- 
times it  occurs  in  old  and  weak  patients  as  a  ter- 
minal complication  in  the  pulmonary  disease.  Most 
often  it  is  due  to  simple  indigestion ;  that  is,  with 
good  diet  and  regimen  it  is  usually  correctable. 

Vomiting  often  occurs  in  pulmonary  tuberculosis, 
and  is  a  troublesome  symptom ;  but  it  comes  mostly 
with  cough  paroxysms,  and  means  little  or  nothing 
as  to  the  condition  of  the  digestive  function.    Some- 


The  Symptoms  of  Tuberculosis  87 

times  it  is  due  to  overloading  the  stomach,  and  a 
very  small  meal  may  be  too  much  for  the  condition 
of  the  patient.  In  such  cases  vomiting  may  be 
remedial,  like  the  vomiting  of  excess  of  milk  by  a 
normal  baby,  or  like  lavage  in  any  case  of  dyspepsia. 

In  women,  if  the  disease  is  contracted  during 
menstruating  life,  this  function  usually  ceases  as 
soon  as  the  patient  becomes  markedly  debilitated. 
This  is  a  symptom  that  expresses  an  effort  of  nature 
to  save  the  life  of  the  patient.  It  is  always  a  mis- 
fortune when  a  tuberculous  woman  menstruates, 
for  she  has  no  surplus  of  blood  to  lose. 

The  rate  of  progress  of  this  disease  varies  greatly. 
Some  people  with  tuljerculosis  of  the  lungs  go  on 
with  their  business,  and  may  recover  while  they 
are  about  it.  They  are  able  by  their  physiologic 
powers  and  forces  to  segregate  the  disease  in  a  part 
of  the  lung,  and  to  destroy  any  small  number  of 
its  bacilli  that  get  into  the  circulation.  Others  fail 
rapidly  even  when  resting.  They  improve  a  little, 
then  get  worse,  have  an  extension  of  the  disease, 
with  catarrhal  pneumonia  aljout  the  seat  of  it,  and 
in  a  few  days  get  up  and  are  better  again ;  but  each 
time,  as  a  rule,  the  im])rovement  following  these 
backsets  is  not  quite  so  great  as  it  was  the  previous 
time;  that  is,  it  fails  to  bring  the  patient  up  to 
his  previous  standard.  Some  of  them  in  their  par- 
tial recoveries  put  on  weight  in  a  remarkable  man- 


88  Tuberculosis 

ner.  A  run-down  patient  goes  away  for  a  vacation ; 
fresh  air  in  abundance  and  rest  soon  improve  him; 
he  gains  what  he  had  lost,  and  gains  more.  From 
being  many  pounds  below  his  normal  weight  he  may 
reach  ten  to  twenty  pounds  above  it.  Most  of  this 
is  made  by  mere  fat,  but  sometimes  it  is  in  a  meas- 
ure due  to  new  muscle  produced  by  athletic  exercise. 
In  either  case  it  is  always  a  misfortune.  Over- 
development of  fat  or  muscle  is  usually  followed  by 
a  relapse  of  the  tuberculosis,  with  reduced  prospects 
of  ultimate  recovery. 

Pulmonary  consumption  is  often  a  remarkably 
painless  disease.  Patients  go  through  the  course  of 
it  and  die,  suffering  almost  no  pain  at  all,  so  that 
some  of  them  say,  as  they  have  many  times  said 
to  me,  that  it  is  a  most  comfortable  disease  to  die 
of.  But  the  majority  of  them  do  have  more  or 
less  pain  from  time  to  time  in  the  walls  of  the  chest, 
in  the  intercostal  nerves  or  pleura,  in  the  abdomen 
from  indigestion,  and  from  some  of  the  complica- 
tions late  in  the  disease.  Joint  pains  with  swelling 
are  not  uncommon.  Sometimes  a  patient  becomes 
very  ner\ous,  although  that  is  exceptional  and  is 
probably  the  result  of  personal  idiosyncrasy. 

I  have  si)oken  of  the  sputum  and  the  things  it 
contains  —  mucus,  Ijlood,  granular  and  calcareous 
matter.  As  the  lung  dissolves,  particles  of  its  tis- 
sue,  in   the  shape  of  curved  fibers  especially,   are 


The  Symptoms  of  Tuberculosis  89 

present,  and  may  be  found  by  the  aid  of  the  micro- 
scope. It  practically  never  happens  that  the  patient 
expels  a  mass  of  the  lung  of  any  considerable  size, 
although  physicians  sometimes  fancy  this  to  occur 
when  shreads  of  buf¥-colored  fibrin  are  coughed  up 
following  a  hemorrhage.  Once  in  a  thousand  cases 
perhaps  a  small  fragment  of  lung-tissue  is,  from  the 
spread  of  the  disease,  suddenly  cut  off  from  its  base 
of  nutrition  and  becomes  gangrenous.  Then  the 
breath  of  the  patient  emits  an  intense  aromatic 
fetor,  and  he  may  expectorate  a  little  piece  of  lung- 
tissue  with  darkish  fluid,  with  or  without  blood. 
I  have  never  seen  such  a  piece  larger  than  the  end 
of  my  little  finger.  The  things  that  we  usually  find 
in  the  sputum  that  show  that  the  lung  is  dissolving 
are  substantially  nothing  but  the  fibrous  tissue  of 
the  walls  of  the  air-vesicles,  fibers  curled  in  various 
shapes  that  w^e  recognize  as  such  under  the  micro- 
scope. But  many  times,  in  examining  sputum  in 
progressing  phthisis,  we  fail  to  find  anything  of 
this  kind. 

A  few  years  ago  we  were  taught,  and  believed, 
that  fever  per  sc  is  extremely  hazardous  to  life.  Now 
we  know  that  such  is  not  the  case,  and  that  one  may 
tolerate  fever  for  a  long  time  with  only  moderate 
harm.  Therefore  a  little  increase  in  temperature 
for  some  hours  of  every  day  in  a  phthisical  patient 
consists  with  fair  nutrition,  and  some  patients  actu- 


90  '  Tuberculosis 

ally  gain  in  weight  under  these  conditions.  I  have 
known  a  patient  to  have  fe\er  every  afternoon  for 
a  year  and  finally  recover,  and  not  lose  very  much 
in  weight  during  the  time.  It  is  the  thing  that 
produces  fever  that  often  destroys  life,  and  if  this 
continues  long  enough  and  the  influence  is  profound, 
of  course  it  wears  out  the  resisting  power  and 
death  ensues.  It  is  therefore  the  poisoning  of  the 
system  by  the  tuberculosis  and  pus  products,  and 
not  the  fe\'er,  that  destroys  life  in  the  end. 

Some  patients  are  cut  off  by  hemorrhage  and 
other  accidents,  and  by  various  complications  of 
the  disease.  In  the  average  case,  where  fever  oc- 
curs only  a  part  of  the  day,  the  temperature  at  cer- 
tain other  times  is  likely  to  be  subnormal ;  that  is, 
it  is  likely  to  be  subnormal  if  the  patient  is  in  a 
debilitated  state  —  his  vigor  much  depreciated. 
During  the  first  six  months  of  the  disease  a  patient 
who  has  a  good  deal  of  physical  vigor,  but  a  little 
fe\-er  e\-ery  afternoon,  will  ha\-e  a  normal  tempera- 
ture night  and  morning,  and  will  not  appear  to  fail 
much.  Let  this  go  on  until  there  supervenes  mark- 
ed debility  and  some  cachexia,  and  in  the  morning 
he  will  probably  have  a  subnormal  temperature  to 
the  extent  of  one  degree  or  more. 

It  is  instructive  to  observe  that  fever  is  always 
made  worse  by  influences  that  put  a  strain  on  the 
powers  of  life.     A  patient  with  a  temperature  of 


The  Symptoms  of  Tuberculosis  91 

100°  F.  in  the  afternoon,  when  he  is  quiescent,  will 
have  it  rise  to  101°  or  102°  F.  if  he  walks  two  or 
three  blocks  or  holds  a  vexatious  conversation  or 
one  involving  a  mental  strain  of  any  kind.  It  is 
therefore  not  true  that  fever  is  always  induced  solely 
by  poisoning.  In  the  study  of  fever  as  a  pathologic 
process  we  have  heretofore  rather  assumed  that 
there  is  only  one  thing  that  produces  it  —  namely, 
poisoning  or  infection.  The  experience  with  tuber- 
culous patients  has  negatived  this  theory  to  some 
extent,  and  that  experience  is  worth  a  great  deal. 
A  medical  friend  had  for  some  little  time  a  slight 
daily  fever  (not  from  tuberculosis,  but  probably 
from  a  form  of  malaria),  and  he  found  that  by  play- 
ing a  round  of  golf  or  taking  other  active  exercise 
his  temperature  would  rise  higher  at  once.  The 
truth  must  be  that  exercise  and  excitement  raise  the 
temperature  when  the  system  is  being  poisoned  by 
some  toxin  which  it  is  trying  to  get  rid  of,  but  only 
succeeds  in  keeping  in  abeyance,  and  when  the  exer- 
cise and  strain  would  not  otherwise  produce  any 
such  effect.  This  explains  how  we  may  save  the 
lives  of  some  patients  by  keeping  them  still. 

The  sweats  of  phthisis  are  a  great  trouble  to  the 
patients  and  their  friends.  There  is  a  popular  no- 
tion that  night-sweats  are  inimical  to  life;  and  if 
a  patient  perspires  a  little  in  the  night,  he  calls  it 
a  night-sweat  and  is  liable  to  be  greatly  distressed 


92  Tuberculosis 

about  it  and,  if  the  sweat  is  profuse,  to  insist  upon 
having  some  drug  to  stop  it  at  once.  Most  of  the 
sweatings  of  these  patients  are  shght,  occurring 
al)out  the  head,  neck,  and  shoulders,  scarcely  ever 
being  sufficient  in  quantity  to  more  than  moisten 
the  night-clothing  —  never  enough  to  wet  the  bed. 
They  are  a  matter  of  little  consequence.  There  are 
probably  a  dozen  medical  students  in  every  class 
of  a  hundred,  who,  if  working  hard  preparing  for 
examinations,  have  the  same  condition  at  night  and 
take  no  notice  of  it.  This  perspiration,  if  it  means 
anything  at  all,  is  a  useful  thing.  Perspiration  rids 
the  system  of  poisons.  The  perspiration  of  a  healthy 
person,  if  injected  in  small  quantity  beneath  the 
skin  of  a  little  animal,  will  generally  prove  harm- 
less; but  if  that  of  a  patient  with  typhoid  fever  or 
some  similar  grave  poisoning  is  used,  the  animal 
immediately  becomes  sick  and  may  die.  The  colliq- 
uative sweats  are  a  great  annoyance  to  the  patient. 
They  make  him  feel  disagreeable;  they  wet  the  bed, 
even  to  the  mattress,  give  him  a  chilly  sensation 
if  he  gets  uncovered,  and  he  is  made  unhappy  from 
that  condition,  and  more  so  because  he  thinks  it  is 
a  very  grave  thing  and  may  even  mean  death.  I 
have  seen  patients  recover  after  having  this  kind 
of  a  sweat  every  night  for  many  months.  Tt  is 
unproven  that  the  sweating  does  any  particular 
harm.      The  patient   may  declare  that  the   night- 


The  Symptoms  of  Tuberculosis  93 

sweats  are  killing  him,  but  it  is  not  true.  The 
patient  may  be  dying,  but  if  he  is,  it  is  from  the 
thing  that  causes  the  night-sweats.  The  sweat  evac- 
uates a  lot  of  saline  water  as  well  as  effete  matter, 
and  drinking-water  and  table-salt  can  easily  replace 
the  needed  elements  to  the  blood. 

Every  patient  has  more  or  less  short-windedness, 
and  this  fact  is  one  of  the  most  useful  hints  for 
diagnostic  purposes.  It  is  perfectly  natural  that  he 
should  be  short-winded,  and  he  always  is  to  some 
degree,  and  the  annoyance  from  this  is  considerable, 
particularly  when  he  exercises.  Even  when  he 
passes  into  recovery  it  does  not  stop,  but  sometimes 
goes  on  progressively  for  a  long  time.  It  does  not 
cease  until  the  deposit  of  fibrous  tissue  in  the  lung- 
ceases;  and  the  fibrosis  probably  always  continues 
to  increase  for  some  time  after  the  tuberculosis  is 
healed. 

Frequently  a  patient  is  annoyed  by  the  wheezing 
and  rattling  sounds  in  the  chest.  These  are  often 
minified  or  overcome  by  his  lying  on  the  sound  side 
of  the  chest,  if  the  disease  is  one-sided. 

Patients  nearly  always  become  cachectic  to  some 
degree,  and  as  the  disease  progresses  the  cachexia 
becomes  more  profound.  It  will  come  to  be  admit- 
ted, I  think,  that  the  cachexia  should  not  be  known 
by  any  qualifying  name.  I  do  not  know  how  to 
distinguish  cancer  cachexia  from  that  of  tuberculo- 


94  Tuberculosis 

sis.  The  cachexia  of  pernicious  anemia  produces 
usually  more  of  a  lemon  tint  than  the  average  patient 
with  phthisis  has,  but  not  more  than  some  con- 
sumptives have. 

We  hear  a  great  deal  about  the  "  glassy  eye  "  of 
phthisis.  Vv'e  see  repeated  references  to  it  in  gen- 
eral literature,  and  even  in  books  on  medicine.  The 
appearance  is  spoken  of  as  though  it  was  an  actuality 
and  of  some  diagnostic  value,  or  at  least  character- 
istic. But  the  eyes  of  consumptives  are  no  more 
glassy  than  the  eyes  of  other  people  who  expose  an 
equal  amount  of  conjunctival  surface  to  the  effect 
of  reflected  light.  In  any  emaciation  the  fat  be- 
neath the  eyelids  shrinks  or  disappears,  and  the 
eye  opens  a  little  wider  than  usual,  and  so  offers 
a  larger  moist  surface  for  reflection.  This  symp- 
tom, if  such  it  may  be  called,  has  no  diagnostic 
value  under  any  circumstances;  it  is  found  in  any 
emaciation. 

We  must  always  remember  that  in  the  recovery 
from  phthisis  there  remain  damaged  organs;  that 
the  patient  is  always  somewhat  short-winded,  par- 
ticularly if  he  exercises;  if  he  walks  up  stairs  at 
the  usual  pace,  or  lifts  heavy  weights,  it  always 
shows.  No  matter  how  long  a  patient  may  live, 
the  injury  to  the  lung  from  the  disease,  the  thick- 
ened connective  tissue  or  scar-tissue,  always  changes 
the  sounds  of  auscultation  and  percussion.     Slight 


The  Symptoms  of  Tuberculosis  95 

dulness  and  some  bronchial  breathing  can  usually 
be  perceived  over  the  site  of  the  lesion  to  the  end 
of  life. 

I  have  referred  to  some  of  the  complications  of 
tuberculosis,  but  from  the  clinical  standpoint  some 
of  them  ought  to  be  considered  rather  as  natural 
extensions  of  the  disease;  as,  for  example,  the  tu- 
berculosis of  the  larynx,  in  which  the  vocal  cords, 
the  epiglottis,  and  the  arytenoids  may  be  affected. 
But  there  may  be  congestion  of  the  vocal  cords  and 
other  laryngeal  structures  without  ulceration  or 
tuberculous  deposits.  In  the  severe  cases  of  tuber- 
culosis of  the  larynx  there  is  always  partial  or  com- 
plete aphonia,  because  either  the  vocal  cords  are 
tuberculous  or  the  mucous  membrane  of  the  larynx 
is  swollen  at  some  point  near  them,  and  presses 
upon  one  or  both  cords  and  interferes  with  their 
vibration.  If  the  arytenoid  region  of  the  larynx  is 
much  involved,  there  is  nearly  always  dysphagia, 
sometimes  to  an  extreme  degree.  Swallowing  is 
so  painful  as  to  make  starvation  welcome. 

Sometimes  the  pharynx  becomes  tuberculous  and 
is  studded  with  numerous  minute  whitish  deposits. 
The  diseased  pharyngeal  surface  is  always  tender, 
and  deglutition  is  painful.  This  must  not  be  con- 
fused with  the  whitish  appearance  of  follicular  de- 
posits in  the  tonsils.  With  this  latter  condition 
there  may  be  some  deep  discomfort  in  swallowing, 


96  Tuberculosis 

but  never  the  acute  local  tenderness  and  pain  of 
pharyngeal  tuberculosis.  There  will  sometimes  oc- 
cur ulceration  of  the  ear-drums,  usually  late  in  the 
disease,  resulting  in  more  or  less  deafness,  although 
the  patient  may  have  no  discomfort;  indeed,  he 
rarely  has  any  with  this  complication,  and  the  dis- 
charge is  rarely  profuse.  It  may,  howe\-er,  be  fetid. 
A  frequent  symptom  is  diarrhea,  with  more  or 
less  pain  in  the  bowels,  especially  just  before  an 
evacuation.  This  symptom  may  occur  both  with 
and  w^ithout  tuberculosis  of  the  intestines;  more 
often  it  occurs  without  it  and  as  a  casual  result 
of  indigestion.  This  latter  nearly  always  causes 
diarrhea,  either  by  the  discharge  of  insufficiently 
elaborated  material  from  the  stomach  into  the  intes- 
tines, which  directly  provokes  the  diarrhea,  or  l)y 
reduced  digestive  power  in  the  intestines  themselves. 
A  very  common  complication  is  some  rectal  trouble, 
as  hemorrhoids  and  little  abscesses  near  the  anus, 
and  resulting  fistulcC.  This  last  often  gives  little 
inconvenience  or  pain,  but  continues  long;  indeed, 
a  patient  rarely  recovers  from  it  while  he  is  tuber- 
culous. The  ci)ididymis  and  vas  deferens  are  often 
involved;  less  often  the  testicles,  bladder,  kidneys, 
seminal  vesicles,  and  prostate  gland.  And  these 
complications  are  often  borne  for  a  long  time  with 
only  moderate  effect  on  the  health  when  the  lungs 
are  but  slightly  diseased. 


The  Symptoms  of  Tuberculosis  97 

The  albuminuria  that  comes  on  late  in  the  dis- 
ease is  a  serious  thing.  It  may  be  extreme  in 
degree,  may  last  many  months,  and  then  decrease 
or  disappear  entirely  as  the  lung  trouble  improves. 
In  only  a  small  proportion  of  the  cases  do  we  find 
tube-casts  in  the  urine.  In  these  patients  there  is 
probably  always  amyloid  degeneration  of  the  kid- 
neys, which  permanently  impairs  their  functions. 
The  li\'er  sometimes  swells,  and  may  project  down 
as  low  as  the  umbilicus  or  lower.  The  enlargement 
is  uniform,  there  are  no  nodules,  and  no  pain  or 
serious  discomfort  results.  This  complication  may, 
after  enduring  for  a  year  or  more,  actually  disap- 
pear, the  organ  returning  to  its  normal  size  and 
lea\'ing  no  sign  or  symptom  of  reduced  hepatic  func- 
tion. 

Cold  abscesses  occur  in  the  subcutaneous  parts 
occasionally,  resulting  probably  from  some  injury  to 
the  deep  tissues,  as  by  a  blow  or  squeeze  that  may 
have  been  forgotten.  They  are  a  complication  of 
some  gravity,  but  not  necessarily  great  gravity; 
they  are  usually  tuberculous,  and  frequently  heal. 
Thus  their  presence  is  not  inconsistent  with  general 
recovery.  ]\Ieningitis  as  a  complication  always  de- 
stroys life,  but  it  does  not  occur  often  in  the  course 
of  pulmonary  tuberculosis.  Tuberculous  meningi- 
tis occurs  mostly  in  children  who  have  apparently 
no  other  focus  of  tuberculosis,  although  they 
7 


98  Tuberculosis 

usually  have  a  hidden  one  somewhere,  perhaps  in 
some  gland.  Here  the  symptoms  are  those  of  men- 
ingitis in  general,  with  all  their  irregularity  and 
simulation  of  typhoid  and  other  fevers. 

A  very  common  accompaniment  of  the  pulmonary 
disease  is  pleuritis.  There  is  some  question  as  to 
whether  it  should  be  called  a  complication,  for  it 
is  a  fact  that  nearly  ahvays  a  tuberculosis  of  the 
lung  causes  inflammation  of  the  pleural  surfaces 
covering  the  region  of  the  disease.  In  post-mortem 
examinations  we  always  find  adhesions  in  cases  of 
advanced  tuberculosis,  but  we  never  knew,  until  the 
Murphy  method  of  treating  apical  tuberculosis  by 
pleural  inflation  was  used,  how^  generally  pleuritis 
and  adhesions  occur  in  the  earlier  stages  of  the 
disease.  Now  we  find  that  the  inflation  treatment 
cannot  be  employed  except  in  an  early  period  of  the 
disease.  After  the  latter  has  continued  for  a  few 
months  adhesions  are  so  extensive  usually  that  the 
pleural  cavity  cannot  be  inflated.  There  is  sometimes 
no  pain  with  pleurisy,  and  it  rarely  causes  pain  for 
long.  With  each  extension  of  the  disease  there 
is  generally  a  little  pain  for  a  few  days,  and  there 
may  be  in  a  given  case  several  extensions  at  variable 
intervals.  In  exceptional  cases  there  is  a  condition 
of  dry  pleurisy  without  adhesions  but  with  abundant 
friction  sounds,  that  may  continue  for  a  long  time 
with  little  or  no  pain. 


The  Syniptums  of  Tuberculosis  99 

Little  further  need  be  said  about  general  miliary 
tuberculosis,  save  that  it  is  rare  except  as  a  terminal 
event  in  various  forms  of  tuberculosis  where  the 
resisting  power  has  become  greatly  reduced.  This 
profound  reduction  in  vitality  invites  all  sorts  of 
complications  in  numerous  organs,  and  these  fre- 
quently occur  and  lead  to  the  death  of  the  patient. 
Patients  often  die  of  diseases  remote  in  character 
and  location  from  those  with  which  the}-  were  first 
attacked. 


CHAPTER  VII 

THE   PHYSICAL   SIGNS   OF   TUBERCULOSIS 

The  physical  signs  of  the  chest  in  tul:)erculosis 
constitute  a  branch  of  the  subject  that  might  per- 
haps be  considered  entirely  under  the  head  of  diag- 
nosis. But  there  are  some  good  reasons  for  treat- 
ing it  in  a  broader  way,  and  many  of  its  truths  will 
bear  repeating  many  times  over.  The  physical  signs 
are  data  that  we  discover  by  physical  exploration, 
by  study  with  unusual  methods,  by  examining  the 
naked  chest  critically  and  in  a  variety  of  ways. 
They  differ  very  much  from  the  symptoms,  which 
are  largely  the  experiences  which  the  patient  can 
tell  about.  He  can  tell  little  of  his  physical  signs, 
save  occasionally  when  they  are  naturally  related 
in  his  mind  with  the  symptoms,  as  when  he  hears 
and  feels  the  rattling  of  phlegm  which  he  is  expec- 
torating, or  when  he  feels  his  heart  beating  in  a 
place  he  knows  to  be  abnormal. 

The  sul)ject  of  the  physical  signs  of  the  chest  be- 
comes simplified  if  we  consider  for  a  moment  just 
what  is  meant  by  the  terms,  and  what  happens 
inside  the  chest  in  health  and  in  disease.  It  is  like 
trying  to  find  out  what  is  going  on  in  the  next 
room  that  we  cannot  see :    we  try  to  learn  about  it 

ICG 


The  Physical  Signs  of  Tuberculosis       loi 

by  listening  to  the  various  sounds,  including  the  con- 
versation ;  and  perhaps  by  various  physical  tests 
applied  to  the  partitions  and  through  the  cracks 
and  keyholes.  The  methods  must  necessarily  be 
more  or  less  indirect,  and  their  proper  execution 
will  recjuire  judgment  and  carefulness  always. 

To  begin  with,  there  are  to  be  observed  some 
surface  changes  that  are  of  consequence.  One  side 
of  the  chest  expends  less  than  the  other,  and  we 
know  that  there  is  something  inside  that  impedes 
its  free  movement ;  one  side  has  fallen  in  a  little 
or  sunken,  and  we  know  that  some  disease  has  prob- 
ably happened  to  cause  it.  Again,  where  the  light 
strikes  the  emaciated  body  to  make  rib-shadows, 
we  see  that  at  the  lower  part  of  the  chest  some 
organs  move  up  and  down  with  respiration,  but  on 
one  side  they  move  farther  than  on  the  other;  that 
tells  us  that  the  excursion  of  the  diaphragm  is  less 
on  the  one  side  than  on  the  other,  which  argues 
possible  adhesion  of  the  pleura  on  the  side  of  lesser 
motion.  Then  we  may  see  or  feel  the  heart  pulsat- 
ing through  the  chest-wall  —  not  where  it  is  seen 
to  beat  ordinarily,  but  above  it,  between  the  second 
and  third  ribs  to  the  left  of  the  sternum.  That 
tells  us  either  that  the  heart  is  very  large  or  that 
something  that  usually  covers  it  has  disappeared ; 
and  we  remember  that  the  heart  is  covered  by  a 
wedge-shaped  portion  of  the  lung,  and  that  if  this 


I02  Tuberculosis 

covering  were  pulled  away,  the  heart  would  fall 
against  the  chest-wall  and  he  seen  to  beat  through 
it.     So  we  look  for  contraction  of  the  left  lung. 

As  an  indispensable  aid  to  physical  examination 
of  these  parts  we  must  understand  and  keep  in 
mind  what  goes  on  physically  in  a  disease  of  a  lung 
like  tuberculosis.  Such  a  disease  thickens  the  lung; 
then  it  hardens  and  contracts  it.  Hardening  pre- 
cedes contraction;  the  connective  tissue  thickens 
and  liardens.  The  disease  dissolves  the  tissue  in 
places,  hence  cavities ;  it  may  cause  the  partitions 
bet^^•een  the  air-vesicles  to  be  dissolved  in  scattered 
regions,  so  that  the  air-spaces  that  carry  on  the 
respiration  are  larger  than  normal.  There  are  cast 
into  the  bronchi  fluid  and  semi-fluid  substances 
which  the  moving  to  and  fro  of  the  air  disturbs, 
producing  various  sounds  called  rales  and  rhonchi, 
and  which  substances  are  brought  up  as  phlegm 
through  the  trachea  by  air-pressure.  These  changes, 
of  course,  alter  the  structure  and  function,  and  so 
the  physical  signs  of  the  lung.  The  pleuritis  is 
a  thing  outside  the  lung,  and  if  efifusion  takes  place, 
it  compresses  the  organ.  So,  knowing  that  the 
physical  condition  of  the  lung  is  changed  by  the 
disease,  we  resort  to  various  devices  to  see  if  we  can 
discover  through  the  chest-wall  what  is  going  on 
inside.  That  is  the  purpose  of  our  physical  exam- 
ination outside  the  chest. 


The  Physical  Signs  of  Tnljerculosis        103 

The  lung  in  health  is  full  of  air  and  cannot  be 
wholly  emptied  of  it.  And  we  take  advantage  of 
this  fact,  and  use  the  lung  as  a  sound-transmitting 
body.  We  test  its  power  to  transmit  vibrations, 
those  produced  by  ( i )  the  inflow  and  outflow  of 
air,  (2)  by  the  heart,  (3)  by  the  voice,  (4)  by 
various  accidental  conditions,  and  (5)  by  numerous 
artificial  devices.  We  listen  to  the  chest  with  vari- 
ous instruments  or  with  the  ear,  to  see  if  the  sounds 
that  belong  to  health  are  present  or  have  become 
changed;  and  we  have  learned,  by  examining  the 
chest  in  this  way  and  by  a  study  of  post-mortem 
conditions,  what  changes  in  the  lung  produce  certain 
changes  in  the  sound.  In  the  main,  the  changes  in 
the  physical  signs  are  logical ;  when  we  come  to 
reason  about  it,  they  are  mostly,  but  not  altogether, 
what  we  should  expect  with  the  particular  path- 
ologic conditions. 

We  listen  to  the  sounds  of  the  heart  through  the 
lungs ;  that  tells,  by  their  faintness  or  intensity, 
of  the  conditions  of  the  transmitting  lung-tissue. 
There  are  other  vibratory  changes  that  we  listen 
for.  Other  evidence  we  get  by  placing  the  hand 
over  the  chest  when  the  patient  is  speaking;  that 
we  call  vocal  fremitus.  If  you  put  your  hand  on 
the  back  of  the  chair  that  you  are  sitting  in,  you  feel 
the  vibrations  that  your  voice  makes.  Vibratory 
impulses    travel    down    through    the    bronchi    and 


I04  Tuberculosis 

through  the  hings  and  sohd  tissues  of  the  chest 
into  the  chair.  They  are  intensified  by  some  thick- 
ening of  the  lung-tissue.  We  listen  for  the  voice 
and  whisper  with  an  instrument  or  the  naked  ear 
over  various  parts  of  the  chest-surface  to  see  if 
the  sounds  are  transmitted  through  any  part  with 
increased  or  lessened  force.  We  listen  to  these 
sounds  and  make  these  tests  in  the  normal  body  and 
observe  them  in  patients,  and  compare  the  two  lungs 
of  an  individual  with  each  other. 

As  the  lungs  are  changed  structurally,  so  are 
these  signs  changed.  There  are  sounds  produced 
by  the  movement  of  phlegm,  serum,  mucus,  pus, 
and  blood,  by  the  closure  and  opening  of  channels 
through  which  air  rushes.  These  are  adventitious 
or  unnatural  sounds  that  we  know  by  various  names 
as  rale  and  rhonchi,  with  many  variations  of  de- 
scription, as  moist  or  dry,  crackling  or  sibilant, 
coarse  or  fine,  and  many  others.  Then  we  measure 
the  expansion  of  the  chest  and  of  the  sides  by  com- 
parison, and  measure  them  at  rest,  and  observe  their 
motion  and  shape,  and  try  to  learn  if  an}-  abnormal- 
ity has  been  produced  by  disease. 

In  the  practice  of  internal  medicine  we  should 
not  try  to  remember  all  the  possible  changes  by  the 
unaided  power  of  memory,  but  should  learn  to  apply 
all  the  tests  to  cases  and  then  consider  the  signs 
and    symptoms    rationally,    so    that   when    certain 


The   Physical   Signs  of  Tuberculosis        105 

sounds  are  heard  or  certain  signs  are  perceived  they 
shall  have  a  logical  meaning  and  we  may  perceive 
in  imagination  the  physical  changes  that  cannot 
be  seen  with  the  eyes. 

Sometimes  a  machine  known  as  a  spirometer  is 
used  to  measure  the  amount  of  air  that  can  be  ex- 
pelled from  the  lungs  after  a  deep  inspiration,  for 
comparison  with  the  supposed  normal  amount.  This 
apparatus  is  made  much  of  by  some  physicians ; 
and  if  we  could  know  as  to  every  patient  what  his 
lung-capacity  is  when  he  is  well,  and  then  measure 
it  when  he  is  ill,  it  would  prove  of  great  value.  As 
a  matter  of  fact,  we  rarely  know  that,  and  people 
differ  widely  in  the  amount  of  air  they  can  take 
in  and  expel.  It  frequently  happens  that  a  man 
with  tuberculosis  can  blow  more  air  into  the  spiro- 
meter than  some  vigorous  men  in  health.  We  never 
expel  all  the  air  that  is  in  our  lungs;  a  variable 
amount  of  residual  air  is  always  left.  There  are 
some  chest  skeletons  so  constructed  that  they  can 
compress  the  lungs  more  than  others,  and  so  expel 
more  air,  just  as  there  are  people  with  loose  joints 
who  can  contort  their  bodies  into  various  shapes 
that  are  impossible  to  others.  It  is  what  the  patient 
can  expel  rather  than  what  he  can  hold  that  the 
spirometer  tells. 

In  testing  for  vocal  fremitus,  always  put  the  two 
hands  on  corresponding  regions  of  the  two   sides 


io6  Tuberculosis 

of  the  chest;  then  let  the  patient  phonate,  perhaps 
say  "  ninety-nine "  —  that  makes  a  maximum 
amount  of  tremor.  After  having  done  that,  press 
the  ulnar  edge  of  the  fists  or  of  the  extended  hands 
against  the  chest  similarly;  then  cross  the  hands 
and  press  them  against  reverse  sides,  to  correct 
any  errors  in  touch  due  to  right  or  left-handedness. 
Then  test  the  two  sides  successively  with  one  hand. 
Whenever  the  fremitus  is  greater  than  normal,  the 
tissue  of  the  lung  is,  we  argue,  a  little  thickened, 
with  patulous  bronchi,  and  therefore  the  voice  vibra- 
tions are  transmitted  more  vividly;  when  it  is  less 
than  normal,  we  suspect  the  presence  of  fluid  in  the 
pleural  cavity,  or  partial  or  complete  closure  of 
some  of  the  bronchi,  to  inhibit  the  vibrations.  If 
the  bronchi  are  filled  with  phlegm  or  obstructed, 
of  course  they  cannot  transmit  voice  vibrations  and 
produce  fremitus.  It  is  not  always  safe  to  say  that, 
because  there  appears  to  be  reduced  fremitus  in  a 
particular  place,  the  bronchi  are  obstructed,  since 
the  disease  may  be  on  the  other  side  and  cause  in- 
creased vibration  there,  which  may  be  misleading. 
We  use  percussion  as  a  means  of  testing,  in  a 
way,  the  physical  condition  of  the  lungs;  really 
we  learn  by  it  the  amount  of  air  in  particular  re- 
gions, and  to  some  extent  the  size  of  the  air-con- 
taining spaces.  The  best  means  of  percussion,  to 
be  used  when  possible,   is  the  examiner's  fingers. 


The  Physical  Signs  of  Tuberculosis       107 

The  best  way  is  to  press  the  fore  and  middle  finger- 
ends  firmly  together  and  use  them  as  a  hammer, 
using  the  middle  finger  of  the  other  hand  as  a 
pleximeter.  One  can  strike  a  strong  blow  in  that 
way.  The  middle  finger  alone  is  a  good  hammer 
when  used  expertly. 

A  great  number  of  percussion  instruments  have 
been  devised,  many  of  which  are  useful.  The  best 
percussors  are,  first,  a  little  ball  of  metal  over  which 
rubber  is  stretched,  and  attached  to  a  handle;  and 
second,  a  firm  handle  to  which  is  attached  a  metallic 
hammer,  into  a  hole  in  the  striking  face  of  which 
is  fixed  a  projecting  plug  of  rather  yielding  rubber. 
The  former  makes  a  high-pitched  tone  which  can 
be  produced  by  the  gentlest  blow  —  one  that  does 
not  cause  pain  to  the  tenderest  surface,  even  over 
an  inflamed  peritoneum;  the  latter  produces  a  low- 
pitched  tone  more  like  that  made  by  the  finger. 
Each  kind  of  percussion  hammer  produces  tones 
somewhat  different  from  every  other;  so  if  any 
one  of  them  is  to  be  used  for  diagnostic  purposes, 
some  practice  will  be  necessary  to  learn  the  signifi- 
cance of  its  tones.  If  you  percuss  lightly,  you  will 
elicit  sounds  showing  the  condition  of  the  surface 
of  the  lungs;  if  you  strike  heavy  blows,  you  will 
make  sounds  in  which  the  deeper  organs  are  more 
or  less  concerned. 

We  make  what  we  call  auscultatory  percussion  by 


lo8  Tuberculosis 

listening  with  a  stethoscope  over  the  chest  while 
percussing  near  it.  This  is  rarely  used  and  is  not 
very  valualjle.  But  students  should  learn  early  and 
use  often  the  open-mouth  percussion.  If  you  direct 
the  patient  to  open  his  mouth  wide  and  to  breathe 
naturally  through  it  without  noise,  and  then  percuss 
over  a  region  of  lung  that  is  more  or  less  infiltrated, 
you  v^ill  find  the  abnormal  sounds  more  pronounced 
and  get  a  better  idea  of  the  changes  in  the  lung. 
But  you  will  not  find  one  person  in  a  hundred  who 
can  do  this  act  perfectly  the  first  time  he  tries, 
for  it  is  a  psychologic  fact  that  a  person  can  rarely 
do  correctly  on  first  trial  any  maneuver  that  involves 
more  than  a-  single  idea,  as  this  one  does.  With  this 
method  percussion  over  a  thickened  lung,  in  front 
and  near  the  clavicle  especially,  elicits  sounds  of 
higher  pitch  than  wnth  the  ordinary  method.  A 
sound  that  would  be  called  dull  by  the  ordinary 
method  becomes  flat  by  this.  In  many  cases  we 
may  produce  by  heavy  percussion  over  an  apex,  and 
more  vividly  by  this  method,  the  cracked-pot  sound 
—  a  peculiar  click  that  is  not  simulated  by  any  other 
sound.  It  is  brought  out  better  by  percussing  with 
the  fingers  than  with  any  machinery.  Hie  click  is 
probably  due  to  the  striking  together  of  the  sun- 
dered surfaces  within  the  lung,  or  by  the  sudden 
pulling  apart  of  contact  surfaces  by  the  jar  of  the 
chest  produced  by  the  blow.     It  consists  with  small 


The  Physical  Signs  of  Tuberculosis       109 

cavities,  with  bronchi  partially  filled  with  phlegm 
and  surrounded  by  nearly  solid  lung,  and  may  some- 
times be  produced  in  normal  children.  The  per- 
cussion with  the  open-mouth  breathing  is  one  of 
the  most  useful  of  all  methods  for  testing  the  con- 
ditions of  the  upper  front  part  of  the  lungs. 

Sometimes  the  percussion  tones  are  changed  by 
posture.  This  is  evidence  of  fluid  surrounding  the 
lung.  Wherever  there  is  such  fluid  there  is  dulness 
on  percussion,  and  in  a  few  cases  the  liquid  in  the 
pleural  cavity  is  so  manifest  that  a  shaking  of  the 
patient  elicits  a  splashing  sound  that  may  be  heard 
some  distance  away. 

For  auscultation  there  are  but  few  instruments 
that  are  useful,  or  that  are  better  than  the  ear  applied 
to  the  chest.  In  using  a  stethoscope  one  should 
test  the  different  varieties  on  the  market,  and  learn 
to  use  the  one  that  is  best  adapted  to  his  ears. 
There  are  great  differences  among  them,  and  what 
is  perfectly  adapted  to  one  person  may  not  be  used 
with  any  satisfaction  by  another. 

The  best  instrument  is  that  one  which  conveys 
to  the  ear  most  accurately  the  lung  tones,  increased 
in  intensity,  and  with  the  least  disturbance  from 
adventitious  noises.  The  monaural  wood,  hard 
rubber,  or  metallic  stethoscope,  with  oval  chest-piece 
and  slightly  concave  ear-disk,  is  the  best  instrument 
for   faithfulness   of  transmission   and   accuracy  of 


no  Tuberculosis 

tone,  bul  it  is  something  of  an  art  to  use  it,  and 
one  that  many  physicians  ne\er  learn.  More  con- 
venient to  use  about  the  patient,  and  withal  a  very 
satisfactory  one,  is  a  binaural  instrument  with  tul)es 
in  part  flexible  and  in  part  metallic,  that,  by  a  spring, 
press  rather  large  ear-tips  firmly  into  the  ears  and 
at  the  proper  angle  for  the  particular  individual. 
A  hinged  spring  that  makes  the  ear-tips  adjustable 
at  any  angle  is  a  great  convenience,  as  is  also  a  chest- 
piece  with  reversible  ends  of  different  diameters, 
and  fixed  to  the  Y-shaped  metallic  tube  with  a  slip- 
joint  and  devoid  of  screw-threads.^ 

The  phonendoscope  is  a  useful  instrument  when 
made  w^ith  a  firm  metallic  chest-box,  wnth  a  large 
diaphragm  of  hard  rubber  slightly  bulging  in  the 
center,  and  attached  to  metallic  ear-tubes  held  stead- 
ily by  a  reliable  spring.  Thus  constructed,  it  mag- 
nifies the  chest-sounds  beyond  the  power  of  any 
stethoscope,  and  preserves  their  qualities  to  a  re- 
markable degree.  In  effect  it  takes  the  listening  ear 
almost  into  the  chest  cavity.  The  soft-rul)l)er  ear- 
tubes,  with  no  means  of  firm  or  uniform  fit  to  the 
ears,  that  have  been  much  exploited  and  used,  are 
unphilosophical,  cannot  give  uniform  results  and 
ought  to  be  discarded. 

Let  us  now  consider  the  progressing  disease  in  a 
lung  and  see  what  occurs  in  physical  signs.    The  first 

1  The  Ingals  stethoscope. 


The  Physical  Signs  of  Tuberculosis       1 1 1 

change  in  the  lung,  as  a  physical  medium  for  the 
transmission  of  vibrations,  that  actually  occurs  in 
most  cases  of  tuberculosis,  is  a  thickening  of  the 
general  connective  tissue  of  the  organ,  and  of  the 
bronchi  with  their  peribronchial  tissue.  And  it  is 
important  for  us  to  be  able  to  distinguish  the  phy- 
sical signs  at  this  early  period.  The  first  sign  that 
would  naturally  be  searched  for  is  a  trifling  dulness 
on  percussion.  But  that  is  not  the  first  one  that  will 
be  found.  The  first  sign  consists  in  changed  aus- 
cultation sounds,  and  these  are  nearl}^  always  pres- 
ent early.  Rales  may  and  may  not  appear.  A  sud- 
den expiration  or  a  cough  may  abolish  rales  by  car- 
rying the  mucus  along  the  tubes  toward  larger 
diameters ;  or  a  deep  inspiration  may  cause  them  to 
disappear  by  expanding  the  bronchi. 

The  first  change  is  usually  an  expiratory  sound 
a  little  louder  and  longer  than  normal.  We  speak 
of  it  as  a  trifle  rude ;  that  word  is  expressive.  The 
tendency  of  one's  mind  is  to  say  erroneously  that 
it  is  higher  in  pitch.  It  seems  so.  Sometimes  it 
is  higher,  but  often  it  is  not,  but  only  louder  and 
longer.  The  normal  sound  of  expiration  is  a  little 
gentle  puff,  which,  because  it  is  short  and  gentle, 
we  are  wont  to  say  is  low  in  pitch.  When  the  tis- 
sues of  the  lung  begin  to  thicken,  the  expiratory 
sound  is  usually  soon  heard  to  be  slightly  prolonged 
and  louder,  and  so  seems  higher  in  musical  pitch 


112  Tuberculosis 

than  normal.  Thus  we  have  tubular  or  bron- 
chial expiration,  louder  than  the  inspiratory  sound, 
and  yet  in  many  cases  the  inspiratory  sound  is 
louder  than  normal  and  harsh ;  again,  it  is  some- 
times fainter  than  normal,  a  result  sometimes  of 
damage  to  the  air-vesicles.  If  the  bronchi  are  patu- 
lous, the  fremitus  is  a  little  increased  over  the  thick- 
ening as  compared  with  the  other  side. 

It  must  be  remembered  that  for  some  reason  there 
is,  in  health,  over  the  right  apex  a  longer  expirator}' 
sound  than  over  the  left,  and  therefore  a  little  sug- 
gestion of  tubular  breathing.  We  should  be  care- 
ful not  to  confound  the  normal  disparity  between 
the  two  sides  with  disease  of  the  right  apex.  In 
order  to  be  safe  and  accurate,  we  are  frequently 
obliged  to  state  to  the  patient  that  in  the  right  apex 
a  thickening  of  the  connective  tissues  seems  to  have 
been  produced  by  some  inflammation  that  has  oc- 
curred some  time  in  the  past ;  and  that  whether 
it  is  a  fixed  exaggeration  of  the  normal  disparity 
between  the  two  sides,  or  is  pathologic,  time  and 
further  evidence  alone  can  tell. 

To  recapitulate,  we  have :  Prolonged  slightly  tu- 
bular expiratory  sound,  possibly  a  little  elevated  in 
pitch ;  inspiratory  sound  possibly  more  rude,  possi- 
bly suppressed  to  some  degree;  increased  fremitus; 
no  particular  change  in  the  percussion  tone.  These 
are  the  signs  that  we  note  in  the  very  beginning  of 


The   Physical   Signs  of  Tuberculosis        113 

an  infiltration  in  a  lung  region ;  and  we  should 
expect  to  find  them  only  slight  in  degree. 

Let  us  suppose,  now,  that  the  tuberculous  process 
has  gone  on  to  produce  more  marked  thickening; 
that  it  is  simply  an  extension  of  the  condition  first 
described.  Now  the  fibrosis  is  greater,  there  is 
more  thickening  of  the  trabecular  matter  in  the 
neighborhood  of  the  region  of  diseased  lung.  The 
lower  line  of  tuberculous  deposit  in  an  apex  may  be 
at  the  level  of  the  second  rib.  The  signs  that  have 
been  mentioned  are  now  simply  exaggerated  over 
the  apex  where  the  consolidation  exists.  But  the 
fibrosis  extends  to  a  slight  degree  down  perhaps 
to  the  line  of  the  fifth  rib. 

You  see  the  patient  in  the  first  two  months  of  his 
sickness,  and  you  find  the  few  signs  I  have  spoken 
of  at  the  very  apex,  and  possibly  a  few  rales.  At 
the  end  of  another  month  or  two,  if  the  disease 
progresses,  there  is  more  thickening,  indicated  by 
more  extensive  tubular  breathing,  more  adventi- 
tious noises,  and  less  rather  than  more  of  the  pure 
inspiratory  vesicular  murmur.  You  find  now  that 
the  evidence  of  fibrosis  has  extended  far  l:)elo\v  the 
fifth  rib,  and  the  prolonged  expiration  shades  off 
at  this  point  to  the  normal  sounds  at  the  bottom  of 
the  lung.  Now  let  the  process  become  still  more 
extended  and  many  of  the  air-vesicles  filled  with  the 
l)roducts  of  the  disease. the  bronchi  perhaps  narrowed 


114  Tuberculosis 

a  little  by  the  pressure  of  the  contracting  fibrosis 
(for  the  fibrous  deposit  always  contracts  as  it  grows 
oklj,  and  there  is  reduced  resonance  and  elevation 
of  pitch  on  percussion,  otherwise  dulness,  or,  if 
the  condition  is  extreme,  tlatness.  There  are  few 
or  many  rales,  depending  on  the  amount  of  fluid 
discharged  into  the  bronchi. 

Now,  perhaps,  little  cavities  begin  to  form  in 
the  apex,  giving  a  gurgling  sound  as  the  patient 
breathes,  and,  if  they  get  larger,  the  amphoric  sound 
of  true  empty  cavities.  When  there  is  distinct  per- 
cussion dulness  or  flatness,  with  patulous  bronchi, 
there  is  a  peculiar  expiratory  sound  that  is  always 
important  to  be  distinguished.  It  is  a  loud,  pro- 
longed, often  rather  hissing  expiratory  sound  of 
high  pitch,  the  sound  appearing  to  be  near  the  ear, 
while  the  inspiratory  tone  is  shorter  and  fainter 
and  devoid  of  the  quality  of  true  vesicular  murmur. 
This  is  the  true  extreme  bronchial  breathing,  and  is 
exactly  what  you  hear  in  an  ordinary  lobar  pneu- 
monia over  the  region  of  consolidation;  you  hear 
it  also  early  in  pleuro-pneumonia.  In  such  cases, 
sometimes  l)efore  you  can  distinguish  any  change 
by  percussion,  you  will  be  able  to  elicit  this  tubular 
sound  by  auscultation.  Once  heard,  it  can  never 
be  forgotten,  and  its  meaning  is  invariable  that  the 
lung  is  consolidated  around  patulous  bronchial  tubes. 

If  there  befalls  a  large  cavity  that  is  full  of  liquid, 


The  Physical   Signs  of  Tuberculosis        115 

it  fails  to  change  distinctively  the  lung  sounds  by 
auscultation,or  by  percussion  save  to  increase  slightly 
the  dulness.  If  it  becomes  empty  and  its  walls 
are  thick  enough  or  the  surrounding  tissue  firm 
enough  to  pre\xnt  collapse,  we  may  hear  the  am- 
phoric sound,  like  that  produced  by  blowing  across 
the  open  mouth  of  a  bottle. 

Now^  suppose,  as  happens  not  infrequently,  that 
the  fibrosis  does  not  occur  uniformly  over  the  dis- 
eased area,  but  presses  sharply  upon  some  localized 
part  of  a  large  bronchus;  or  suppose  some  of  the 
lymphatic  glands  swell  and  make  such  pressure :  we 
shall  then  hear  exactly  the  sound  that  is  produced 
when  a  large  goiter  presses  against  the  windpipe. 
It  is  a  tubular  sound,  very  loud,  and  simulates  some- 
what the  sound  heard  when  a  stethoscope  is  placed 
over  the  normal  trachea.  The  same  kind  of  a  tone 
is  in  rare  instances  found  to  be  due  to  localized  tu- 
mors  of  the  lungs  —  chiefly  cancer  and   sarcoma. 

As  to  the  sounds  produced  by  moving  air  in  con- 
tact with  phlegm  in  the  lungs,  the  variations  are 
almost  limitless.  We  have  numerous  kinds  of  rales 
and  rhonchi.  Some  we  call  dry  rales,  because  they 
do  not  suggest  fluid;  if  a  bronchus  is  collapsed  at 
some  point,  or  a  little  bunch  of  thick  phlegm  ob- 
structs it,  there  results  the  sibilant  or  whistling 
rale.  The  air  churns  the  semi-fluid  material  in 
the  tubes,  producing  moist  rales;   these  sounds  are 


ii6  Tuberculosis 

sometimes  aptly  described  as  gurgling.  Another 
descripti\e  and  very  good  term  is  crackling  rales, 
the  phlegm  having  become  so  thick  and  sticky  that 
when  it  is  moved  by  the  breath,  crackling  sounds 
are  produced.  We  must  remember  that  all  the 
sounds  produced  by  phlegm  are  things  that  come 
and  go,  and  that  we  may  find  any  such  sort  of  a  rale 
to-day  and  none  to-morrow. 

We  often  hear  over  a  tuberculous  lung  the  friction 
sounds  of  pleural  rubbing.  The  sound  produced 
by  the  slight  movement  upon  each  other  of  the  palms 
pressed  together  firmly  over  your  ear  is  a  good  illus- 
tration of  these  tones.  Of  course,  when  fluid  is 
present  in  the  pleural  cavity,  there  can  be  no  friction 
sounds,  but  dulness  on  percussion.  Sometimes  when 
the  patient  changes  his  posture  the  upper  line  of  flat- 
ness changes  if  there  is  fluid,  but  often  it  does  not 
change,  owing  to  encapsulation.  Over  a  mass  of 
fluid  or  air  or  gas  in  the  pleural  cavity  the  vocal 
fremitus  is  lost,  whereas  over  a  partially  consolidated 
lung,  where  the  bronchi  are  open,  the  fremitus  is 
always  increased.  We  should  avoid  falling  into 
the  rather  common  error  of  thinking,  simply  because 
there  is  flatness  with  some  rales  in  the  lower  part 
of  a  chest,  that  there  is  certainly  consolidation  of 
the  lung-tissue  instead  of  fluid.  When  much  fluid 
is  present,  the  lung  sounds  are  so  distant  that  they 
are  hardly  perceived   unless  the   pleural   cavity   is 


The  Physical  Signs  of  Tuberculosis       117 

severely  distended ;  then  faint  bronchial  and  even 
lung  tones  may  l;e  transmitted  through  it. 

The  voice  and  whisper  signs  are  interesting  in 
tuberculosis.  They  are  not  especially  valuable  in 
late  cases :  the  value  of  the  voice  signs  is  early. 
When  a  point  is  reached  where  pectoriloquy  is  ob- 
tained, it  is  simply  a  curiosity.  At  this  stage  of 
a  case  usually  other  signs  have  already  established 
the  diagnosis.  Bronchophony  is  a  very  valuable 
sign,  but  valuable  at  the  beginning.  Whenever 
there  is  increased  fremitus,  the  voice  signs  are  usu- 
ally increased,  and  this  is  a  valuable  confirmatory 
indication. 

There  are  certain  obstacles  to  learning  these  phy- 
sical signs  that  we  need  to  study  in  a  practical  way. 
You  will  find  ^'ery  soon  that  the  average  patient 
does  not  know  how  to  breathe  for  you  to  listen,  and 
when  making  an  examination  your  calling  his  atten- 
tion to  this  function  fixes  his  mind  on  the  perform- 
ance so  that  he  ceases  to  breathe  naturally.  If  your 
ears  are  acute  to  slight  variations  of  sound,  you  are 
liable  to  become  confused  by  some  adventitious 
tones.  The  chief  trouble  is  with  the  muscle  tones.  Be- 
cause he  thinks  he  is  breathing  for  you  to  listen,  the 
patient  may  take  deep  breaths  and  not  sufficiently 
expel  the  air,  and  use  twice  the  muscular  power 
necessary.  A  muscle  in  the  act  of  contracting 
always  produces  a  slight  continuous  humming  noise 


ii8  Tuberculosis 

that  can  be  heard  with  the  stethoscope.  It  is  a  sound 
that  you  cannot  locate,  but  you  will  recognize  it  as 
a  muscle  tone,  and  know  that  the  patient  is  using 
some  muscles  about  the  chest,  and  using  muscle 
power  not  necessary  for  respiration. 

Many  patients,  when  breathing  for  you,  will  be 
unable  to  breathe  normally;  they  will  breathe  vio- 
lently, with  unusual  force ;  they  cannot  be  tranquil 
about  it.  When  properly  auscultating  a  chest,  it 
is  necessary  that  every  muscle  about  it  not  needed 
for  respiration  shall  be  absolutely  at  rest.  When 
you  enjoin  this  upon  patients  you  will  many  times 
find  it  impossible  for  them  to  obey;  the  harder 
they  try  not  to  have  the  muscles  tense,  the  more 
they  fail  to  succeed.  You  may  sometimes  counter- 
act this  tendency  by  diverting  the  attention  away 
from  the  act  of  breathing.  Have  the  patient  lie 
down  on  his  back,  turn  on  his  sides  alternately,  and 
on  the  abdomen  while  you  listen  over  his  back ;  have 
him  stand  and  bend  his  body  forward.  These 
changes  of  posture  will  sometimes  cause  him  to  for- 
get completely  that  he  is  breathing.  Then  you  can 
hear  the  chest  sounds  most  perfectly.  Deep  inspira- 
tions with  shallow  expirations  is  a  frequent  and 
troublesome  fault  of  breathing  on  the  part  of  a  pa- 
tient who  is  impressed  with  the  fact  that  you  are 
listening  to  his  chest.  This  trick  so  distends  the 
air-spaces  of  all  kinds  as  often  to  abolish  rales  and 


The  Physical  Signs  of  Tuberculosis       119 

bronchial  breathing.  Then  the  patient  should  be 
asked  to  expire  profoundly  and  to  cough  at  the  end 
of  such  an  expiration.  This  maneuver  partially 
collapses  the  air-spaces  and  bronchi  and  nearly  al- 
ways elicits  rales  if  anything  can,  and  brings  out 
the  full  degree  of  bronchial  breathing.  Any 
patient,  by  the  fault  of  breathing  I  have  described, 
thereby  increasing  above  the  normal  his  residual 
air,  can  effectually  hide  from  the  most  careful  aus- 
cultator  both  rales  and  bronchial  breathing  of  mod- 
erate degree.  The  examiner  must  be  watchful  and 
detect  this  usually  unwitting  deception  on  the  part 
of  the  patient,  and  correct  its  errors. 

The  lung  sounds  heard  by  auscultation  are  liable 
to  differ  to  a  very  considerable  degree,  depending 
on  whether  the  patient  is  breathing  through  the 
mouth  or  the  nose;  and  this  difference  is  some 
times  as  marked  over  the  back  as  over  the  front  of 
the  chest.  Several  times  I  have,  while  listening 
over  the  apices,  heard  what  appeared  to  be  a  distinct 
bronchial  tone  that  was  wholly  produced  by  open- 
mouth  breathing  and  which  disappeared  the  moment 
the  patient  began  to  breathe  through  the  nose. 


CHAPTER  VIII 

THE    DIAGNOSIS    OF    TUBERCULOSIS 

For  purposes  of  diagnosis  as  well  as  for  treat- 
ment, it  is  important  to  make,  at  the  first  examina- 
tion of  every  case,  a  careful  record  of  the  local  find- 
ings and  of  the  general  physical  and  symptomatic 
conditions,  as  well  as  the  history  of  the  case  from 
the  beginning.  Then  subsequent  examinations,  the 
results  of  which  should  also  be  recorded,  will  show 
the  progress  of  the  disease  for  better  of  for  worse. 
No  less  precise  method  than  this  is  to  be  commended. 
The  practice  followed  by  some  physicians  of  trying 
to  remember  the  conditions  from  time  to  time  of 
all  their  chest  cases  is  a  loose  and  reprehensible 
custom.  It  begets  unscientific  habits  of  mind  that 
are  sure  in  the  end  to  tell  against  the  interests  of 
patients ;  and  it  leads  to  many  blunders  in  prescrib- 
ing. 

Many  methods  of  case-taking  and  recording  have 
been  devised,  and  various  charts  and  blanks  have 
been  recommended.  But  the  most  useful  for  the 
painstaking  physician  is,  I  believe,  a  plain  piece  of 
paper  with  outline  drawings  of  the  human  body, 
especially  of  the  chest,  on  which,  by  various  marks 
and  characters,  the  pathologic  findings  may  be  re- 

I20 


The  Diaonosis  of  Tuberculosis 


121 


corded.  So  simple  a  scheme  as  this  is,  I  am  sure, 
far  better  than  some  of  the  complicated  recoird 
charts  now  in  use.  The  accompanying  cut  (Fig".  2) 
illustrates  the  chart  used  by  the  author,  with  signs 
to  indicate  the  various  more  common  changes  of 
disease.  It  is  not  offered  as  anything  perfect,  but 
simply  as  a  useful  tool  which  any  one  may  vary. 


Fig.   2. — Author's   chart    with    illustrative   markings. 

//     Bronchial    hreathing    and    dulness,    marked.       Increased 

voice,   whisper,   and   vocal   fremitus. 
—     Reduced  vesicular  murmur. 

II     Rales,  mostly  moist. 
\>^     Flatness   on   percussion,    with    reduced   fremitus  and  al)- 

scnce  of  lung  sounds. 
O     Cracked-pot     sound     on     percussion     with     open-mouth 

hreathing.     Amphoric  sound  moderate. 
00     Faint  and   distant   amphoric   sound. 
XX     Frictions. 

The  intensity  of  the  signs  is  in  proportion  to  the  heaviness 
and  the  numhcr  of  strokes  or  marks. 


122  Tuberculosis 

In  the  care  of  the  sick  there  are  few  things  of 
more  importance  than  the  early  discovery  of  tuber- 
culosis;  for  early  diagnosis  makes  possible  the  most 
effecti\-e  treatment — which  is  early  treatment — and 
if  made  in  every  instance,  it  would  lead  to  a  great 
increase  in  the  already  large  percentage  of  recover- 
ies from  this  disease. 

But  we  never  can  expect  to  make  early  diagnoses 
until  we  appreciate  a  truth  that  is  usually  overlooked 
—  namely,  that  tuberculosis,  especially  in  the  lungs, 
always  exists  for  a  considerable  time  before  it  an- 
nounces itself  by  signs  or  symptoms.  It  is  some- 
times present  for  a  long  time  before  symptoms  ap- 
pear, and  our  only  proper  course  is  to  be  alert  for 
the  first  hint  of  any  evidence  that  can  point  to  its 
existence. 

Probably  it  can  never  be  known  positively,  but 
there  is  little  reason  to  doubt  that  tuberculosis  may 
exist  in  the  walls  of  the  bronchi  for  weeks  be- 
fore it  induces  enough  irritation  to  cause  notice- 
able cough;  and  it  may  exist  a  very  long  time  be- 
fore any  conscious  local  irritation  is  produced.  It 
must  be  rare  that  marked  fever  occurs  —  if  it  occurs 
at  all  —  until  some  degree  of  mixed  infection  has 
been  produced  by  suppuration  at  the  point  of  lesion. 
This  las't  event  often  occurs  through  some  broken 
surface,  some  ulceration  of  the  bronchial  mucous 
membrane  produced  by  the  increase  of  the  superficial 


The  Diagnosis  of  Tuberculosis  123 

tubercles  which  are  cut  off  from  efficient  blood-sup- 
ply. Before  pus- formation  the  only  general  symptoms 
would  be  some  slight  depreciation  of  the  vital 
powers  —  perhaps  some  lowering  of  the  weight  and 
some  sensations  of  fatigue  on  exercise. 

Tuberculosis  of  the  lungs  is  prolific  in  simula- 
tions of  other  diseases,  and  when  the  ideal  signs 
in  the  chest  are  absent,  we  are  frequently  in  great 
perplexit)^  The  disease  then  sometimes  resembles 
tuberculous  meningitis  and  mild  typhoid  fever;  it 
frequently  simulates  mild  malarial  fever;  it  resem- 
bles fevers  produced  by  slo\v  infection  through  some 
pus  focus,  or  a  leaking  cyst  somewhere  in  the  body 
that  produces  no  local  signs.  When  focal  signs 
are  absent,  we  must  hunt  for  evidence  pointing  to 
the  correct  diagnosis.  Loss  of  weight,  debility, 
cough,  and  indigestion  should  always  lead  to  the 
suspicion  of  tuberculosis,  and  in  every  case  of  pro- 
longed low  fever  we  should  promptly  suspect  this 
form  of  infection.  It  is  the  most  common  of  all 
diseases  producing  long-continued  fever,  and  we 
should  never  study  a  case  of  the  latter  without  con- 
sidering the  possibility  of  tuberculosis.  We  some- 
times forget  this  when  there  are  no  focal  signs ;  and 
where  there  is  a  history  of  cough  extending  over  a 
considerable  time,  we  sometimes  guess  the  case  to 
be  one  of  simple  bronchitis. 

I  wish  to  refer  agfain  to  the  lather  valueless  char- 


124  Tuberculosis 

acter  of  the  percussion  tones  early  in  the  disease. 
If  the  disease  were  always  unilateral,  and  if  we  could 
be  sure  that  the  air-vesicles  had  before  possessed 
the  same  physical  characters  in  the  two  lungs,  and 
if  we  all  had  musical  ears  and  could  discriminate 
sharply  as  to  pitch,  resonance,  and  quality  of  tone, 
then  percussion  early  would  l)e  valuable.  Late  in 
the  disease  it  is  always  valuable;  but  early  it  is 
often  misleading,  and  has  differing  significations  to 
different  examiners,  as  determined  by  their  varying 
degree  of  expertness  in  tone.  In  incipient  cases 
there  is  always  abundant  resonance,  and  physicians 
often  make  the  mistake  of  assuming  that  there  is 
no  lung  disease  because  there  is  no  dulness  or  other 
change  perceptible  on  percussion.  The  average  ])er- 
son  is  a  poor  judge  of  minute  changes  in  percussion 
pitch.  Take  a  case  where  you  suppose  you  have 
on  one  side  distinct  elevation  in  pitch  or  slight  dul- 
ness ;  then  have  a  musical  expert  come  in  and  listen 
to  your  percussicMi.  and  see  him  correct  your  reck- 
oning! He  will  probably  say  that  your  supposed 
higher  tone  has  the  same  pitch  as  that  of  the  well 
side,  the  only  dift'erence  being  one  of  quality.  I 
would  give  a  hundredfold  more  for  a  careful  study 
of  the  changed  expiratory  sound  on  auscultation,  as 
showing  the  beginning  of  tuberculosis,  than  for  any 
slight  change  in  the  percussion  signs.  If  some  of 
the  air-vesicles  near  the   diseased  area  happen   to 


The  Diagnosis  of  Tuberculosis  125 

be  dilated,  the  cause  of  duhiess  that  otherwise 
would  exist  is  neutralized;  but  disease  signs  still 
appear  in  the  auscultation,  especially  if  it  is  prac- 
tised with  various  kinds  and  degrees  of  breathing. 

We  often  fail  to  make  a  critical  examination  of 
both  sides  of  the  chest.  We  sliould  always  do  this 
for  comparison,  and  take  time  to  do  it  well.  It  is 
never  enough  to  listen  to  one  side  where  the  disease 
is  supposed  to  be.  We  should  listen  on  the  two 
sides  alternately,  traversing  with  the  stethoscope 
from  apex  to  base  of  both  lungs,  the  patient  mean- 
while breathing  deeply  (especially  expiring  fully) 
at  our  direction,  and  note  any  difference  between  the 
two  sides, —  note  where  it  is,  and  its  character  and 
degree.  If  there  is  thickening  in  the  apex,  there 
is  sure  to  be  at  the  top  a  more  distinct  and  longer 
expiratory  tone  and  increased  fremitus,  both  of 
which  shade  off  to  normal  conditions  lower  down  the 
lung.  In  regions  where  the  expiratory  .=ound  is  a 
little  louder  and  longer  than  normal,  the  vesicular 
murmur  on  inspiration  is  also  usually  somew^hat 
lessened.  These  signs  mean  a  thickening  of  the 
connective  tissue  of  the  lung  where  the  changed 
breathing  exists  —  a  change  due  to  some  disease 
process  still  going  on  or  that  has  existed  at  some 
previous  time. 

In  searching  for  slight  changes,  in  cases  where 
the  disease  is  beginning,  we  must  not  only  note  the 


126  Tnljerciilosis 

differences  as  we  hear  them  under  the  usual  con- 
ditions of  respiration,  but  the  patient  must  exhale 
forcefully  and  cough  at  the  end  of  such  an  expira- 
tion, to  show  what  differences  can  be  demonstrated 
between  different  parts,  and  to  demonstrate  rales 
that  otherwise  might  be  hidden.  Where  the  relative 
difference  is  greatest,  whether  at  the  top  or  the 
bottom  of  the  lung,  there  is  the  focus  of  the  disease, 
and  the  signs  shade  off  toward  the  other  parts  of  the 
organ.  You  listen  at  the  bottom  of  both  lungs 
and  find  the  tones  exactly  alike:  listen  a  little 
higher,  and  the  tones  of  both  inspiration  and  expi- 
ration become  slightly  different  in  the  two  lungs; 
go  up  toward  the  top,  and  the  expiratory  sound  is 
perhaps  distinctly  tubular,  with  reduced  vesicular 
murmur  on  one  side  while  there  are  normal  tones 
on  the  other.  This  positively  locates  the  focus  of 
disease  at  the  top. 

\\q  not  infrequently  find  a  slight  lessening  of  the 
vesicular  murmur  with  possible  slight  increase  in 
fremitus  over  a  whole  lung  and  uniformly,  and  no 
other  sign.  For  this  demonstration  the  back  is  per- 
haps the  best  place  to  listen,  although  the  difference 
can  be  made  out  on  the  sides ;  it  is  less  easily  found 
in  front.  The  changes  referred  to  mean  that  some 
disease,  perhaps  at  some  long  previous  time,  has 
involved  the  whole  surface  of  the  lung  and  left  its 
effects  as  a  permanent  condition.     Pleuritis  is  the 


The  Diagnosis  of  Tuberculosis  \2y 

disease  that  most  often  produces  this  effect.  When 
a  patient  comes  to  you  with  vague  chest  symptoms, 
and  you  find  the  vesicular  murmur  shghtly  lessened 
all  over  one  lung,  with  slightly  increased  fremitus 
and  no  physical  signs  besides,  you  may  say  with  a 
considerable  degree  of  certainty  that  a  general  pleu- 
ritis  has  occurred  at  some  previous  time.  The  pa- 
tient may  promptly  confirm  this,  or  perhaps  at  first 
deny  it,  then  remember  that  he  did  have  a  pleurisy 
several  years  before.  Pleurisy  unconnected  with 
lung  disease  is  likely  to  involve  the  whole  covering' 
of  the  lung  or  a  large  part  of  it.  It  always  leaves 
a  little  thickening  of  the  surface  of  the  lung  as  well 
as  the  pleura,  so  that  ever  afterward  there  is  a  slight 
reduction  in  the  vesicular  murmur  over  the  region. 
Now,  it  happens  occasionally  that  you  find  tubercu- 
losis in  the  other  lung  —  a  condition  of  things  that 
is  very  confusing ;  for  there  are  then  the  focal  signs 
of  a  deposit  on  one  side,  and  uniform  reduction  in 
vesicular  murmur  over  the  other.  This  makes  it 
seem  as  though  the  tuberculosis  had  actually  in- 
creased the  vesicular  murmur  over  the  whole  of  the 
infected  lung. 

It  is  usually  easy  to  demonstrate  in  a  lung  the 
presence  of  a  cavity  of  large  size  if  it  is  empty  and 
connected  with  a  bronchus ;  but  small  cavities  often 
exist  for  months  without  producing  any  sign  what- 
ever.    Amphoric  sound  depends  on  a  cavity  of  some 


128  Tuberculosis 

size  open  to  the  movement  of  air  into  and  out  of 
it  or  across  its  open  mouth.  A  cavity  of  moderate 
size  might  contain  air,  but  might  have  its  opening 
into  the  bronchus  closed  at  the  moment  of  ausculta- 
tion, and  there  would  be  no  amphoric  sound.  And 
the  tympanic  percussion  tone  of  a  cavity  is  never 
produced  by  a  small  excavation  or  by  one  full  of 
fluid  —  but  flatness  is  more  likely  instead. 

A  number  of  physicians  think  they  can  demon- 
strate cavities  where,  I  am  sure,  none  exist.  The 
pure  and  ideal  tubular  breathing  is  sometimes  mis- 
taken for  evidence  of  a  cavity;  or  it  is  this  sound 
with  coarse  rhonchi,or  the  latter  alone, or  some  other 
and  perhaps  unusual  tone  that  is  similarly  far  re- 
moved from  the  amphoric  breathing  and  voice,  that 
is  seized  upon  as  proof  of  cavity.  On  the  other 
hand,  small  cavities,  and  many  of  them  at  once, 
often  exist  and  give  no  evidence  of  their  presence 
except,  perhaps,  by  gurgling  rales. 

Sometimes  loud  rales  and  rhonchi  confined  to  one 
lung  are  transmitted  through  the  large  bronchi  to 
the  other  lung,  and  give  an  impression  to  the  aus- 
cultator  that  it  also  is  diseased.  This  mistake  is 
not  infrequent,  and  sometimes  seems  almost  una- 
voidable. But  the  illusion  can  usually  be  detected 
by  first  noting  carefully  the  character  of  the  rales 
in  the  lung  known  to  be  diseased,  and  then  tracing 
them  toward  the  other  lung  step  by  step  with  the 


The  Diagnosis  of  Tuberculosis  129 

stethoscope.  If  the  rate  and  character  of  the  rales 
and  their  relation  to  the  acts  of  inspiration  and  ex- 
piration remain  the  same  on  receding  from  the  dis- 
eased lung, —  if  the  only  change  is  merely  a  growing 
faintness  of  tone, —  we  may  be  sure  the  sounds  are 
transmitted.  If,  on  the  other  hand,  the  character 
and  relation  change,  then  the  sounds  originate  in  the 
other  lung,  and  both  organs  are  diseased. 

The  presence  of  the  curved  fibers  of  the  walls  of 
the  air-vesicles  in  the  sputum  is  of  some,  but  not 
great  diagnostic  importance,  for  it  rarely  reveals 
much  evidence  that  cannot  be  found  by  auscultation 
and  percussion.  It  does,  indeed,  tell  of  the  melting 
away  of  some  of  the  air-vesicle  walls;  but  this  may 
occur  from  any  ulceration  besides  that  of  tuberculo- 
sis, and  when  it  is  due  to  this  disease,  considerable 
fibrosis  nearly  always  is  present.  The  examination 
for  the  fibres  is  not  difficult  to  make.  Boiling  the 
sputum  in  a  solution  of  caustic  soda  for  a  few  min- 
utes makes  it  quite  liquid ;  then  it  may  be  diluted 
with  cold  water,  and  sedimentetl  by  standing  in  a 
conical  glass  or  l:)y  means  of  the  centrifuge;  then 
a  drop  of  the  sediment  is  placed  under  the  micro- 
scope with  a  low  power,  and  tlie  fil)ers  appear. 

It  is  not  safe  to  say  that  a  patient  has  tuberculo- 
sis of  the  lungs  because  he  has  any  or  all  the  chest 
signs  so  common  to  phthisis.  For  there  are  cases 
—  rare,  indeed,  but  they  exist  —  of  non-tuberculous 
9 


1 30  Tuberculosis 

phthisis  that  almost  perfectly  simulate  the  tubercu- 
lous. Therefore  it  is  necessary  to  search  the  sputum 
for  bacilli  in  every  case.  Once  found  they  should 
never  be  expected  to  disappear  so  long  as  purulent 
expectoration  continues,  unless  this  comes  from  the 
inside  of  an  old  cavity. 

The  differentiation  of  tuljerculosis  and  typhoid 
fever  ought  not  to  be  difficult  or  long  delayed,  for 
in  the  latter  condition  we  have  almost  invariably, 
after  eight  days,  the  positive  result  of  the  Widal 
blood  reaction,  so  that  the  test  of  time  and  the  mi- 
croscope very  soon  mark  the  line  between  these  two 
diseases.  Malarial  fever  can  be  told  by  finding  the 
Plasmodia  in  the  lilood  with  the  microscope;  and 
any  practitioner  with  a  good  instrument  can  learn 
to  make  the  examination.  Fever  states  due  to  local 
disease  sometimes  present  more  difficulty,  but  the 
focus  nearly  always  gives  some  other  sign  or  symp- 
tom besides  fever  that  points  to  it.  Where  a  fever 
continues  with  cough  and  expectoration,  and  espe- 
cially if  the  slightest  change  can  be  detected  in  the 
lung,  we  should  always  regard  tuberculosis  as  more 
than  half  proven. 

The  tuberculin  test  for  the  presence  of  tuljercu- 
losis  is  a  safe  and  relatively  reliable  procedure  to  be 
resorted  to  in  cases  of  doubt.  We  can  inject  hypo- 
dermically  from  i  to  5  milligrams,  starting  with 
not  more  than  2  (i  is  better),  and  if  tuberculosis  is 


The  Diagnosis  of  Tuberculosis  131 

present,  the  temperature  .will  rise  two  to  three  de- 
grees above  its  usual  maximum,  beginning  in  a  vari- 
able period  of  four  to  twelve  hours,  and  continuing 
from  four  to  thirty  hours.  There  will  be  some  of 
the  usual  symptoms  of  a  febrile  attack,  as  chilliness 
at  the  onset  of  the  fever,  headache,  general  pain, 
restlessness,  possibly  nausea,  weakness,  and  rapid 
pulse.'  As  the  fever  subsides  all  these  symptoms 
will  gradually  disappear.  If  there  Is  no  reaction 
after  the  first  injection,  it  may  be  repeated  once  or 
twice  at  Intervals  of  a  few  days.  The  second  dose 
may  be  double  the  first,  and  so  on  for  three  or  four 
doses,  the  last  being  8  or  10  milligrams.  If  then 
no  febrile  reaction  results,  we  may  conclude  with 
a  fair  degree  of  certainty  that  tuberculosis  does  not 
exist. 

There  may  be  congestion  and  swelling  of  the 
diseased  regions  as  a  local  reaction  to  the  tuberculin. 
This  occurs  In  conjunction  with  the  general  reac- 
tion of  fever,  and  may  be  observed  readily  in  tuber- 
culous skin,  glands,  joints,  and  larynx,  but  is  not  as 
easily  made  out  by  auscultation  and  percussion  In 

1  Dr.  C.  M.  Wood,  formerly  in  charge  of  the  Hospital 
for  Consumptives  in  Ciiicago,  formulates  the  following  tests 
of  a  perfect  reaction  from  tuberculin. 

1.  The  rise  in  temperature  must  amount  to  at  least  two 
degrees. 

2.  It  must  reach  its  height  between  six  and  twenty-four 
hours  after  the  injection,  except  in  fibroid  cases,  where  it  may 
be  delayed  thirty-six  hours. 

3.  It  must  be  accompanied  by  at  least  two  of  the  following 
symptoms :    Chilliness,  headache,  nausea,  and  muscular  pains. 


1 32  Tuberculosis 

the  affected  areas  of  the  lung'.  It  undoubtedly  oc- 
curs in  all   internal  forms  of  the  disease. 

In  using  this  test,  great  care  should  be  taken  to 
get  reliable  lymph.  The  test  should  not  be  attempt- 
ed on  febrile  cases,  but  only  on  those  whose  temper- 
ature, if  at  all  above  normal,  is  but  slightly  so,  and 
constant  for  many  days  together.  In  making  the 
test  the  temperature  should  be  taken  every  two  hours 
for  a  day  before  the  injection  and  as  often  for  a 
day  afterward,  in  order  to  be  sure  of  the  precise 
effect  of  the  procedure. 

A  few  years  ago  many  physicians  suspected  that 
injections  of  tuberculin  might  cause  an  extension 
of  the  disease  throughout  the  body.  This  fear  no 
longer  prevails,  and  no  such  result  follows  its  use. 
The  fact  of  the  local  reaction  to  tuberculin  has 
encouraged  the  fear  of  the  spread  of  the  disease; 
but  with  the  tentative  dosage  advised,  and  the  slight 
local  change  resulting,  there  is  probably  no  danger 
at  all,  even  if  a  profound  reaction  were  capable  of 
doing  harm.  And,  even  assuming  a  marked  reac- 
tion, it  is  not  all  certain  that  it  could  set  free  into 
the  circulation  swarms  of  bacilli  without  which  no 
extension  can  occur.  The  local  reaction  is  a  con- 
gestive process  about  the  fficus  of  the  disease,  and 
may,  for  all  we  know,  l)e  restrictive  of  the  bacilli 
and  actually  prevent  their  dissemination.  More- 
over, the  presence  of  a  small  (|uantity  of  tuberculin 


The  Diagnosis  of  Tuberculosis  133 

in  the  blood  (and  with  any  fair  vigor  of  system) 
must  logically  be  expected  to  beget  some  power  or 
thing  that  acts  the  part  of  an  antitoxin  to  tubercle 
bacilli,  rather  than  to  encourage  their  growth. 

Syphilis  occasionally  gives  a  febrile  reaction  to 
tuberculin ;  and  a  reaction  may  possibly  occur  from 
a  very  large  dose  injected  into  a  healthy  person. 
On  the  other  hand,  reaction  sometimes  fails  to  occur, 
even  from  a  liberal  dose,  in  an  advanced  case  of 
consumjition.  These  drawbacks  only  slightly  im- 
pair the  value  of  the  tuberculin  test,  for  its  percent- 
age of  failures  in  early  cases  and  with  proper  dosage 
is  very  small.  And  it  is  in  the  incipiency  of  the 
disease  tliat  the  test  is  most  useful. 

In  making  the  injections,  aseptic  precautions 
should  be  strictly  observed,  as  well  as  care  for  the 
size  of  the  dose.  Tuberculin  properly  prepared  is 
of  uniform  strength  and  will  keep  almost  indefi- 
nitely. For  convenience  in  using,  it  may  be  diluted 
to  a  10  per  cent.  solutifMi  in  distilled  water  contain- 
ing 2-5  per  cent,  of  carbolic  acid  —  a  solution  that 
also  keeps  indefinitely.  At  the  time  of  administra- 
tion a  I  per  cent,  solution  may  be  made  by  diluting 
the  first  solution  to  tenfold  w'ith  distilled  water; 
this  represents  i  milligram  of  tuberculin  in  lyi 
minims. 

One  of  the  latest  discoveries  is  that  the  blood- 
serum  of  tuberculous  patients  actually  agglutinates 


134  Tuberculosis 

the  bacilli  of  tuberculosis.  It  causes  them  to  gather 
together  in  clumps,  as  is  the  case  in  the  Widal  reac- 
tion of  typhoid  fever.  Certain  other  diseases  have 
the  same  peculiarity;  that  is.  the  blood-serum  of  a 
l)erson  who  has  had  the  disease  destroys  pure  cul- 
tures of  the  causing  bacilli.  Thus  it  has  been  dem- 
onstrated that  the  Bacillus  dysenteria:,  causing  the 
dysentery  of  the  West  Indies  and  the  Philippines, 
in  pure  culture  is  agglutinated  by  the  blood  of  the 
patient ;  so  the  Widal  method  is  not  restricted  to 
typhoid  fever.  I  should  say  that  this  agglutination 
by  the  serum  in  tuberculous  cases  is  no  m(~)re  reliable 
than  the  tuberculin  injection  in  any  case,  and  is 
prol)ably  much  less  reliable  in  the  slight  cases  where 
the  diagnosis  is  doubtful. 

The  cases  of  joint,  bone,  gland,  and  skin  tuber- 
culosis are  all  announced  by  symptoms  and  signs 
that  are  more  or  less  distinctly  focal.  Many  of 
these  affections  are  surgical  in  their  character,  and  I 
shall  not  discuss  them  at  length  here.  I  wish  to 
say,  however,  that  where  the  joints,  bones,  or  ten- 
don-sheaths are  involved  in  any  lesion  that  pro- 
duces pain,  tenderness,  or  swelling,  we  should  al- 
ways suspect  tuberculosis,  whether  it  exists  in  the 
lungs  or  not;  for  this  infection  frequently  produces 
such  lesions.  Of  course,  if  one  of  these  lesions 
occurs  in  the  course  of  a  lung  tuljerculosis,  we  would 
more  naturally  think  of  it.     Frequently  we  fail  to 


The  Diagnosis  of  Tuberculosis  135 

think  of  it  if  the  hmgs  are  not  evidently  diseased 
and  if  the  patient  is  not  physically  debilitated.  In 
susceptible  subjects  a  blow  or  other  violence  is  likely 
at  any  time  to  lower  the  vitality  of  one  of  these  parts 
so  that  tuberculosis  may  supervene. 

Tuberculous  meningitis  requires  special  study  for 
diagnosis,  because  it  differs  in  many  ^\'ays  from 
other  forms  of  tuberculosis.  It  occurs  mostly  in 
a  class  of  young  patients  who  are  wanting  in  any 
easily  discoverable  evidence  of  infection  of  the  lungs 
or  of  any  other  part  of  the  body.  It  occasionally 
comes  as  a  late  phenomenon  in  lung  cases,  and  then 
we  have  no  difficulty  in  diagnosis.  Children  have 
tuberculous  meningitis  more  often  than  adults,  and 
with  them  it  often  appears  as  an  apparently  initial 
lesion.  There  is  evidence  that  the  bacilli,  entering 
the  blood  from  some  previously  existing  focus  of 
tuberculosis,  are  carried  to  the  meninges,  and  at  the 
base  of  the  brain  find  their  way  through  the  capil- 
laries and  light  up  the  disease.  It  produces  a  set 
of  symptoms  that  are  the  most  amazing  of  any  to 
be  found  in  all  the  practice  of  medicine,  because 
they  are  so  irregular  and  so  atypic. 

It  is  impossible  to  describe  a  case  of  tuberculous 
meningitis  so  that  one's  first  case  of  the  disease  shall 
surely  tally  with  that  description.  Pain  is  one  of 
the  first  symptoms,  but  it  does  not  always  appear; 
it  usually  comes  early,  but  sometimes  not  until  late 


136  Tuberculosis 

in  the  disease.  It  occurs  usually  as  an  irregular 
sharp  pain  in  the  head,  but  sometimes  it  is  a  pro- 
longed, disagreeable  ache.  Sometimes  the  head  is 
drawn  back  in  opisthotonos,  and  then  the  meninges 
of  the  spinal  cord  are  invohed ;  but  this  symptom 
is  usually  absent. 

Fever  always  occurs  some  time  during  the  course 
of  the  disease;  usually  it  1)egins  as  a  trifling  eleva- 
tion of  temperature,  and  each  successive  day,  for  a 
number  of  days,  it  rises  exactly  as  in  the  so-called 
classical  typhoid  fever.  Sometimes,  however,  the 
fever  is  entirely  irregular;  it  may  occur  as  a  quick 
explosion,  the  temperature  rising  rapidly  and  re- 
maining for  a  day  or  two  as  in  remittent  fever  or 
the  initial  fever  of  measles  or  scarlet  fever;  then  it 
subsides,  and  for  a  time  the  ])atient  seems  to  be  con- 
valescent so  far  as  the  fever  is  concerned ;  then  the 
fever  returns. 

The  appetite  is  lost,  the  patient  may  vomit  occa- 
sionally, or  for  a  brief  period  he  may  eat  voraciously 
and  digest  his  food.  He  usually  has  constipation, 
but  not  always.  These  general  symptoms  are  ex- 
tremely perplexing.  There  is  not  one  of  them  that 
points  very  positively  toward  the  brain,  except  it 
be  the  pain.  That,  indeed,  does  hai)pcn  in  the  brain 
disease;  Imt  children  frequently  have  pain  in  the 
head  with  other  diseases.  They  have  migraines  like 
adults,   and   great  pain   in   the  head   with   various 


The  Diagnosis  of  Tuberculosis  137 

trifling  ailments,  and  there  is  nothing  surprising 
about  it.  So  it  happens  that  this  disease  in  the 
early  stages  is  very  frequently  taken  for  other  af- 
fections. Probably  it  is  most  commonly  taken  for 
typhoid  fever.  This  error  is  sometimes  unavoidable 
during  the  first  few  days,  but  never  after  eight  or 
ten  days;  and  cases  of  tuberculous  meningitis  may 
last  a  week  or  ten  days  before  focal  symptoms  ap- 
pear. After  a  case  has  continued  for  ten  days,  the 
Widal  test  should  settle  the  question  as  to  typhoid 
fever. 

The  patient  with  tuberculous  meningitis  loses 
weight  rapidly,  but  not  more  rapidly  than  is  often 
the  case  in  typhoid  fever.  In  a  few  days,  however, 
usually  from  four  to  ten,  general  symptoms  occur 
that  point  unmistakably  to  the  cerebrum.  One  of 
these  is  strabismus,  convergent  usually,  but  some- 
times divergent.  The  pupils  become  unequal  in 
size.  That  does  not  prove  meningitis,  because 
sometimes  people  in  ordinary  health  have  one  pupil 
larger  than  the  other  as  a  result  of  fatigue ;  but  with 
other  symptoms  it  may  be  a  valuable  sign.  In 
meningitis  the  pupils  become  later  immobile.  That 
always  reveals  brain  disease. 

Then  the  ])ulse  becomes  irregular,  showing  that 
the  regulating  machinery  of  the  heart,  that  manifests 
itself  through  the  pneumogastric  nerve,  is  regulat- 
ing the  rate  imperfectly;    the  pulse  is  rapid,  then 


138  Tuberculosis 

slow.  It  does  not  drop  a  beat  occasionally,  as  in 
functional  disorders  of  the  heart,  but  is  slow  and 
fast  alternately.  Then  if  we  draw  the  finger-nail 
over  the  skin  of  the  abdomen,  we  find  that  the  red 
line  produced  by  it  appears  and  disappears  slowly 
if  the  case  is  one  of  tuberculous  meningitis.  This 
is  what  is  known  as  cerebral  or  meningeal  tache, 
and  is  a  sign  of  some,  but  not  great,  diagnostic 
value,  since  it  appears  in  other  conditions.  It  is 
a  result  of  vaso-motor  paresis. 

The  abdomen  becomes  flat,  and  then  sinks  late  in 
the  disease.  Finally  the  patient  ceases  to  be  able 
to  vomit,  and  refuses  to  take  food  unless  forced  to; 
he  frequently  emits  a  little  whine  or  cry,  and  he 
is  always  unconscious,  and  therefore  wholly  insen- 
sible of  suffering.  Various  distortions  of  his  body 
may  occur.  One  of  the  limbs  may  be  drawn  up  in 
spasm,  or  the  eyes  may  be  drawn  to  one  side. 

A  valuable  diagnostic  pointer  in  this  late  stage 
of  the  disease  is  lumbar  puncture  —  puncturing  the 
lumbar  region  of  the  spinal  canal  with  a  tubular 
needle.  In  meningitis  there  is  an  excessive  amount 
of  spinal  fluid, —  really  an  excess  of  cerebro-spinal 
fluid,  for  the  fluid  in  the  subarachnoid  space  con- 
nects with  that  of  the  spinal  canal.  For  this  opera- 
tion all  that  is  needed  is  a  hypodermic  syringe  with 
a  long  needle,  or  a  small  detached  aspirating  needle. 
All   ordinary   aseptic   precautions  should   be  taken 


The  Diagnosis  of  Tuberculosis  139 

with  instruments,  hands,  and  field  of  operation.  The 
patient  should  sit  or  lie  with  the  body  bent  slightly- 
forward,  and  the  needle  should  be  held  in  such  a 
way  as  to  prevent  its  being  plunged  in  too  deeply. 
Three-quarters  of  an  inch  for  a  child  is  a  sufficient 
depth  usually;  twice  as  much  for  an  adult.  The 
needle  should  be  inserted  slightly  to  one  side  of  the 
spines  of  the  vertebrae,  and  be  pushed  carefully  up- 
ward and  inward  toward  the  spinal  canal.  The 
point  of  election  is  below  the  second  or  third  lum- 
bar vertebra.  If  there  is  an  excess  of  spinal  fluid, 
it  will  be  drawn  into  the  syringe,  or  will  drop  from 
the  needle  if  this  is  detached  from  the  syringe.  In 
this  manner  a  dram  or  two  of  the  fluid  may  be 
drawn  in  a  case  of  meningitis.  The  fluid  may  be 
clear  and  almost  colorless,  or  opalescent  from  pus 
or  leukocytes,  or  it  may  contain  particles  of  fibrin- 
ous material  or  blood.  In  tuberculous  meningitis 
bacilli  may  often  be  found  in  the  fluid  by  staining  the 
sediment  procured  by  the  centrifuge. 

Of  cases  of  tuberculous  pleuritis  little  need  be 
said.  We  cannot  tell  the  tuberculous  from  the  non- 
tuberculous.  Some  insist  that  the  cases  are  all  tu- 
berculous, Vk^-hich  is  not  true,  though  the  majority 
doubtless  are  so.  The  physical  signs  are  simply 
those  of  pleurisy.  Whether  the  deposit  in  the  pleu- 
ral cavity  is  in  the  shape  of  firm  or  pasty  material 
that  makes  friction,  or  organized  material  that  fin- 


I40  Tuberculosis 

ally  compresses  the  lun<4',  or  whether  it  is  serum 
or  pus, —  if  there  is  much  of  it,  it  will  produce 
duluess  on  percussion,  the  degree  depending  on  the 
amount  of  it.  It  will  lessen  or  abolish  the  vesicu- 
lar murmur  of  the  lung  beneath  it.  If  a  chest 
cavity  is  so  full  of  serum  or  pus  as  to  put  it  upon 
the  stretch,  it  will  transmit  vibratory  impulses. 
Then  distant  faint  Ijreath-sounds  from  the  lung 
above  or  from  the  opposite  side  may  be  heard.  This 
is  a  prolilic  source  of  error  on  the  part  of  students 
and  young  practitioners.  They  discover  percussion 
flatness,  but  because  they  hear  the  lung  sounds  e\'en 
faintly,  they  forget  about  the  condition  of  the  inter- 
costal spaces,  the  situation  of  the  heart,  and  the 
fremitus,  and  conclude  that  the  case  cannot  be  one 
of  fluid  in  the  pleura. 

When  fluid  is  present  in  any  considerable  amount, 
the  intercostal  spaces  are  sure  to  be  less  sunken  than 
normal ;  they  are  more  full,  although  \-ery  rarely 
bulging.  This  intercostal  space  sign  is  nearly  diag- 
nostic of  the  presence  of  fluid.  A  tumor  may  cause 
the  dulness  and  lack  of  fremitus,  and  even  dis- 
place the  heart,  but  it  is  rarely  of  sufiicient  size  to 
spread  over  a  surface  extensive  enough  to  produce 
a  uniform  bulging  of  the  spaces.  In  case  of  any 
degree  of  doubt,  one  should  always  explore  the 
chest-cavity  with  a  large  aseptic  hypodermic  needle, 
and,  if  possible,  procure  some  of  the  contents.     This 


The  Diagnosis  of  Tuberculosis  141 

will  usually  clear  up  the  diagnosis.  We  should  be 
careful  that  the  syringe  works  and  will  make  suc- 
tion, and  that  the  skin  is  surgically  clean.  With 
relative  absence  of  fremitus  and  of  lung  sounds  (or 
the  remoteness  of  them  from  the  ear),  short-wind- 
edness, and  the  displacement  of  the  heart,  in  addi- 
tion to  the  intercostal  sign,  the  diagnosis  should  be 
plain. 

If  the  effusion  is  on  the  left  side,  the  heart  is 
pressed  to  the  right,  and  vice  versa.  The  first  sus- 
picion should  always  be  that  the  displacement  of 
the  heart  is  due  to  pressure ;  it  may  be  due  to  con- 
traction. But  the  apex  beat  may  be  moved  by  en- 
largement of  the  heart,  and  with  no  disease  of  the 
pleura  or  of  the  heart-valves  or  portals.  Then,  of 
course,  the  urine  should  be  examined  for  fibroid 
disease  of  the  kidneys  —  a  condition  that  is  always 
attended  with  arterio-fibrosis.  We  should  never 
regard  as  complete  the  examination  of  a  patient  who 
has  flat  percussion  sound  over  the  lower  part  of  one 
side  of  the  chest,  until  we  have  made  the  needle 
puncture.  It  cannot  always  be  done,  but  its  omis- 
sion sometimes  leads  to  humiliating  errors  in  diag- 
nosis. Under  the  safeguarding  of  surgical  cleanli- 
ness it  is  a  harmless  procedure,  and,  properly  done, 
it  is  substantially  painless.  The  l)est  way  to  do  it 
is  to  press  a  forefinger  firmly  into  the  proper  inter- 
costal  space,  the  palmar  surface  l)eing  downward 


142  Tuberculosis 

and  pressed  more  against  the  lower  rib;  then  to 
plunge  the  needle  boldly  into  the  chest,  sliding  it 
over  the  finger  nail  as  a  guide.  The  pressure  of 
the  finger  obtunds  or  diverts  the  sensibility  of  the 
part  so  much  that  the  prick  of  the  needle  is  often 
not  felt  at  all. 

The  X-ray  is  of  some,  but  not  great,  value  in  the 
diagnosis  of  chest  diseases.  It  reveals  slight  shading 
over  regions  of  lung  that  are  deeply  infiltrated  with 
tuberculosis,  when  seen  by  the  fluoroscope;  \X  is  less 
satisfactory  w^ien  studied  by  the  radiograph.  The 
motions  of  the  heart  can  be  seen  by  the  fluoroscope, 
and  the  movements  of  the  diaphragm.  But  the  nec- 
essary apparatus  is  costly,  and  difficult  to  use,  and 
it  reveals  little  or  nothing  that  cannot  be  demon- 
strated by  the  usual  exploration  that  is  within  the 
reach  and  capacity  of  every  physician. 


CHAPTER   IX 

THE  PROGNOSIS  OF  TUBERCULOSIS 

The  prognosis  of  tuberculosis  is  of  the  greatest 
importance  both  to  the  individual  and  to  the  public. 
Will  this  patient  get  well?  What  is  the  prospect 
of  recovery?  These  are  intense  questions  daily 
asked  of  the  physician.  Years  ago  a  patient  v^ith 
tuberculosis  of  the  lungs  was  supposed  to  be  doomed 
to  die.  It  was  thought  then  that  relatively  fewer 
people  have  the  disease.  Now  we  know  that  at 
least  half  of  all  the  people  have  it  some  time,  and 
that  a  large  proportion  of  them  reco\'er  entirely, 
while  in  a  vast  number  the  focus  of  disease  becomes 
encysted  and  harmless. 

As  to  the  morbidity  of  the  disease,  some  patholo- 
gists hold  that  70  per  cent,  of  all  people  have  tubercu- 
losis somewhere  in  their  bodies,  some  time  in  their 
lives;  others  put  it  as  low  as  40  per  cent.  I  think  we 
may  safely  say  that  half  the  peoi)le  have  tuberculosis 
somewhere,  some  time.  It  shows  strikingly  the 
prevalence  of  this  disease  that  Chicago  in  forty-two 
years  lost  39,000  people  from  the  pulmonary  form. 
The  disease  kills  30  times  as  many  people  as  variola 
and  scarlet  fever  together,  16  times  as  many  as  ty- 
phoid  fever,   8  times  as  many  as  diphtheria,   and 

143 


144  Tuberculosis 

4.5  times  as  many  as  all  combined.  In  New  South 
Wales,  in  twelve  years,  ^2  per  cent,  of  all  deaths 
from  tuberculosis  were  from  phthisis,  and  "j.y  per 
cent,  were  due  to  tuberculous  meningitis.  During 
the  same  time  the  deaths  from  the  six  chief  zymotic 
diseases  were  only  75  per  cent,  as  many  as  died  from 
tuberculosis.  In  Ireland,  in  1895-97  inclusive,  the 
mortality  from  tuberculosis  was  11.5  per  cent,  of  all 
deaths,  which  were  17.3  per  thousand  of  population 
per  annum. 

The  mortality  increases  irregularly  with  age,  and 
yet  hardly  any  one  would  suppose  so.  The  pop- 
ular belief  is  that,  in  proportion  to  their  number, 
young  people  suffer  more  deaths  from  tuberculosis 
than  older  people ;  yet  it  has  been  found  by  earlier 
census  reports,  that  there  are  more  l^etween  sixty 
and  seventy  years  of  age.  In  proportion  to  the  liv- 
ing, deaths  from  tuberculosis  are  more  frecjuent 
between  those  years  than  in  any  other  time  of  life 
—  showing,  pr()l)al)l}',  that  lowering  of  vitality  by 
work,  age,  other  diseases,  and  the  vicissitudes  of 
life  and  of  seasons  invites  phthisis  and  makes  re- 
covery from  it  impossil)le.  These  statements  do 
not  even  hint  at  the  proportion  of  deaths  to  the 
cases  of  the  disease. 

The  last  census  reports  of  the  United  States  show 
that  the  proportion  of  deaths  was  greatest  between 
70  and  80  years,  the  mortality  from  phthisis  [)eing 


The  Prognosis  of  Tuberculosis  145 

during  that  decade  1.91  times  greater  than  the  pro- 
portion of  the  Hving  at  that  age;  while  at  the  age 
of  the  greatest  mortality  in  proportion  to  all  deaths 
from  the  disease  —  20  to  30  years  —  the  ratio  was 
only  1.59.  The  following  table  and  Chart  I  show 
the  proportion  of  deaths  from  consumption  at  dif- 
ferent ages,  and  the  proportion  of  the  living  at  the 
same  ages,  in  percentages  of  the  whole  population. 
Chart  II  shows  how  the  fluctuations  in  the  deaths 
from  the  disease  at  different  ages  compare  with 
the  proportion  of  the  living  at  the  same  ages. 

This  information  from  the  census  as  to  deaths 
is  interesting  and  instructive.  It  is  greatly  to  be  re- 
gretted that  we  have  no  means  of  know'ing  the  pro- 
portion of  people  at"  the  different  ages  who  acquire 
the  disease,  as  well  as  that  of  those  who  die  of  it. 

It  will  be  observed  that  at  no  time  of  life  do 
the  deaths  from  consumption  correspond  exactly 
with  the  proportion  of  living  people  of  the  same  age. 
Except  during  the  first  four  half-decades  of  life, 
the  proportion  of  deaths  from  this  disease  to  all  the 
deaths  from  it  is  far  above  the  proportion  of  people 
living  at  the  same  ages,  save  during  the  two  half- 
decades  from  45  to  54  inclusive. 


10 


146  Tuberculosis 


Tabic  sJiozviiig  deaths  from  Coiisitinplion  at  cer- 
tain ages,  in  percentages  of  tJic  total  deaths  from 
t/iis  disease,  and  tlie  proportion  of  living  persons 
at  the  ages  shozcn,  in  percentages  of  the  ivJwle  popn- 
lation.  Compiled  from  United  States  Census  Re- 
ports, 1900. 


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Under  5 4.08  12.07  501054 5.01  3.87 

5  to    9 1. 18  11.68  55  to  59 4.06  2.91 

10  to  14 2.12  10.63  60  to  64 3.35  2.35 

15  to  19 8.35  9.95  65  to  69 2.93  1.71 

20  to  24 14.71  9.72  70  to  74 2.19  1. 16 

25  to  29 14.51  8.65  75  to  79 1-33    -68 

30  to  34 11.75  7-34  80  to  84 56    .33 

35  to  39 9-'98  6.55  85  to  89 19    -n 

40  to  44 7.68  5.60  90  to  95 044    -03 

45  to  49 5-25  4-55 


The  Prosnosis  of  Tuljerculosis 


147 


CHART   I. 

S/wzving  t/ic  (Icai/is  from  Coiistniiptioii  at  dif- 
ferent ages,  ill  percentages  of  the  total  deaths  from 
this  disease:  also  the  proportion  of  the  liz'tng  at 
these  ages,  i:i  percentages  of  the  zchole  population. 
Compiled  from  Reports  of  the  United  States  Census 
of  1900. 

Solid  line,  deaths;  dotted  line,  population. 


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'"^■ 

148  Tuberculosis 

The  records  of  post-iiiortcins  in  late  years  are  sur- 
prising. Out  of  3067  autopsies,  it  was  found  ihat 
41.86  per  cent,  had  tuberculous  lung  lesions,  and  in 
11.97  P^^  cent,  these  lesion  were  healed,  or  28.5  per 
cent,  of  all  the  tuberculous  cases.  Of  826  bodies 
where  death  was  due  to  acute  non-tuberculous  dis- 
eases or  to  accidents,  tuljerculous  lesions  were  found 
post-mortem  in  the  lungs  of  20.7  per  cent,  of  them, 
of  which  4.2  per  cent,  were  incipient,  3.8  per  cent, 
were  rather  extensive,  and  12.7  per  cent,  were  fib- 
rous or  healed.^  That  is,  8  per  cent,  of  these  people 
(38.6  per  cent,  of  the  tul)erculous  cases)  had  more 
or  less  active  forms  of  tuberculosis.  Therefore  61.4 
per  cent,  of  all  the  tuberculous  cases  in  this  series 
must  ha\e  become  quiescent  and  harmless  by  abso- 
lute cure  or  encystment  and  segregation.  In  an- 
other series  reported  by  Koehler,  about  26  per  cent, 
of  dissected  bodies  showed  vestiges  of  tuberculosis, 
and  in  all  these  cases  death  from  tuberculosis  was 
positively  excluded.  These  bodies  were  from  among 
the  poor  and  unfortunate. 

It  is  an  old  record  and  an  old  doctrine  that  one- 
seventh  of  all  people  die  of  tuberculosis ;  that  is 
over  14.25  per  cent,  of  all  deaths.  These  figures 
have  been  quoted  so  often  and  so  long  that  they 
seem  like  a  law  of  nature.  But  they  are  wrong  for 
this  day,  whatever  authority  they  may  have  had. 

1  Birch-Hirschfeld. 


The  Prognosis  of  Tuberculosis 


149 


CHART  II. 

Showing  the  fluctuations  in  deaths  from  Con- 
sumption at  different  ages  (in  ratio  of  all  deaths 
from  the  disease)  as  compared  zuith  the  number  of 
the  living  at  the  same  ages.  The  heaz'y  hori:;ontal 
line  indicates  the  proportion  of  the  living;  the  zig- 
zag line  shows  the  deaths.  (Compiled  from  the  U. 
S.  Census  Reports  of  1900.) 


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1 50  Tuberculosis 

The  mortality  from  all  forms  of  tuberculosis  now  is 
not  over  1 1  per  cent,  of  all  deaths,  and  that  from 
the  pulmonary  form  probably  does  not  much,  if  at 
all,  exceed  9  and  loj/  per  cent,  in  rural  and  urban 
populations  respectively.  Koehler  puts  the  mortal- 
ity from  consumption  in  cities  at  2.25  per  1000  peo- 
ple per  annum  (with  a  total  mortality  per  1000  of 
21.8),  or  10.3  per  cent,  of  all  deaths. 

The  United  States  census  of  1900  shows  10.56 
per  cent,  of  all  deaths  reported  in  the  registration 
sections  of  the  country  for  the  previous  year  to  have 
been  due  to  "  consumption."  The  census  of  "  gen- 
eral tuberculosis,"  being  added,  brought  the  propor- 
tion up  to  10.68  per  cent.  These  figures,  it  must 
be  remembered,  do  not  apply  to  the  whole  country, 
but  to  the  "  registration  area," —  mostly  towns  and 
cities  where  the  census  officials  believed  that  fairly 
accurate  records  could  be  procured. 

The  Public  Health  and  ]\Iarine-Hospital  Service 
of  the  United  States  has  compiled  the  mortality  sta- 
tistics of  1435  cities,  towns,  and  villages  in  this 
country  for  the  year  1901,  with  this  result:  Total 
deaths,  365,216;  from  "tuberculosis,"  41,938,  or 
1 1.4  per  cent,  of  all  deaths.  This  is  more  than 
double  the  number  of  deaths  from  enteric  and  scarlet 
fevers,  measles,  and  diphtheria  comljined,  these  dis- 
eases having  destroyed  20,787  people. 

It  is  rather  surprising  that  the  figures  from  the 


The  Prognosis  of  Tuberculosis  151 

two  sources  quoted  should  vary  so  much.  There 
is  no  doubt  of  the  effort  at  accuracy  of  the  persons 
engaged  in  the  work  of  registration  and  compila- 
tion ;  their  differing  views  as  to  classification  of 
diseases  and  the  diagnosis  of  the  causes  of  death, 
together  with  the  human  tendency  to  error  in  figures 
and  records,  would  make  some  disparity  unavoid- 
able. The  records  from  the  two  sources,  moreover, 
do  not  cover  exactly  the  same  communities ;  and 
it  is  to  be  regretted  that  we  have  no  such  adequate 
records  of  mortality  in  the  rural  districts  as  we 
have  in  the  cities  and  towns.  The  farming  com- 
munities certainly  have  a  lower  death-rate  than  the 
cities  and  towns. 

In  Germany  in  1895  t^"*^  mortality  from  consump- 
tion was  1 0.22 "per  cent,  of  the  total  mortality.  The 
deaths  from  this  disease  numbered  215.3  in  each 
100,000  of  the  population.  The  death-rate  per  1000 
of  population  was  21.06. 

The  death-rate  from  tuberculosis  is  declining, 
especially  in  communities  where  repressive  measures 
are  in  vogue.  The  United  States  census  of  1890 
showed,  in  the  registration  area,  that  the  deaths 
from  consumption  and  general  tuberculosis  combined 
were  12,146  for  each  100,000  deaths  from  all  causes, 
or  12.14  per  cent,  of  all  deaths;  while  the  census  of 
1900  showed  10,688  to  each  100,000  deaths,  or 
10.68  per  cent,   of  the  total   mortality.      In    1890 


1 52  Tuberculosis 

there  were  245.4  deaths  from  tuberculosis  in  each 
100,000  of  the  population;  while  in  1900  the  num- 
ber had  fallen  to  190.5.  These  figures  show  a  re- 
duction in  the  ratio  of  deaths  from  tuberculosis  to 
total  deaths  of  nearly  ly^  per  cent.,  and  an  actual 
lessening  of  deaths  from  the  disease  of  over  22  per 
cent,  of  the  higher  figure,  or  more  than  one  for  each 
week  in  every  community  of  100,000  people. 

This  saving  of  life  is  probably  to  some  extent 
more  apparent  than  real ;  it  probably  does  not  rep- 
resent 54.9  fewer  cases  of  tuberculosis  in  the  given 
community,  but  in  part  speaks  for  the  better  care 
of  the  cases,  and  so  the  postponement  of  the  deaths 
of  some  of  them.  This  argument  applies  to  the 
decade  just  passed,  which  has  witnessed  a  great 
improvement  in  the  care  of  consumptives.  It  may 
not  apply  to  future  decades.  But,  allowing  for  this 
element  and  for  possible  errors  in  computation,  there 
still  can  be  no  doubt  that  the  mortality  from  tuber- 
culosis is  on  the  decrease  in  this  country. 

The  mortality  from  consumption  in  Italy  is  de- 
creasing. The  annual  deaths  per  100,000  people 
during  1887  to  1889  inclusive  were  107.53;  during 
the  three  years  1895  to  1897  inclusive  the  rate  had 
fallen  to  102.63.  This  means  a  reduction  from  the 
higher  figure  of  4.5  per  cent. 

In  Liverpool,  during  the  decade  ending  with  1875, 
among  100,000  people  there  were  430  deaths  from 


The  Prognosis  of  Tuberculosis  153 

this  disease,  or  4.3  per  1000;  the  next  decade  there 
were  309  deaths,  or  3.09  per  1000;  and  in  three 
recent  years  256  deaths,  or  2.56  per  1000.  The 
deaths  in  nine  cities  of  Europe  for  the  decade  ending 
1890  were  3.82  per  1000  people;  while  for  the  same 
time  in  twenty-eight  American  cities  it  was  2. 68. 
In  Prussia,  prior  to  1889,  the  deaths  from  lung 
tuberculosis  were  annually  3.14  per  1000  people. 
In  the  following  eight  years  it  was  2.18  per  1000. 
In  New  York  City  the  mortality  from  tuberculosis 
since  1886  has  dropped  35  per  cent,  of  its  previous 
rate  (Biggs).  In  Prussia,  in  1880-86,  the  deaths 
from  consumption  were  31 1.2  per  100,000  people; 
in  1895  the  rate  had  fallen  to  232.6. 

The  mortality  from  consumption  at  different  ages 
and  of  the  two  sexes,  as  revealed  by  the  last  census, 
makes  a  chapter  of  the  greatest  interest.  The  num- 
ber of  deaths,  which  is  low  during  the  first  three 
half-decades  of  life,  mounts  rapidly  during  the  next 
two  or  three,  whence  it  falls  steadily  to  the  seven- 
teenth (80th  to  85th  year).  The  mortality  among 
females  during  this  period  is  lower  than  that  of 
males,  except  during  the  second  to  seventh  half- 
decades  inclusive  (5th  to  34th  year),  when  it  is  con- 
siderably higher,  especially  during  the  years  from 
15  to  30.  Chart  III  shows  the  facts  in  a  graphic 
manner. 


154 


Tuberculosis 


CHART  III. 

Relative  deaths  from  Consumption  in  the  two 
sexes,  shown  by  half-decades  of  life,  in  the  census 
"  registration  area,"  in  whicli  the  deaths  for  the 
year,  from  all  causes,  numbered  1,039.094.  The 
solid  line  indicates  males;  tJie  dotted  line,  females. 
(Compded  from  the  U.  S.  Census  Reports  of  1900.) 


Ages 

Judt 
lyr. 

r2 
to  4 
incl. 

to 

SI 

14 

to 
19 

24 

29 

to 
34 

39 

40 
to 
44 

45 
to 
49 

00 
to 

'to 

59 

00 
04 

09 

70 
to 
74 

76 
to 

79 

SO 
to 

S4 

85 
to 

«9 

90 
to 

94 

Ovc< 

95 

Number 

of  Deaths 

9600 

9000 

}' 

92 

8500 

• 

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57 

8000 

1 

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; 

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20 
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44 

4j 
to 

49 

JO 
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54 

50 

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to 

04 

05 
to 
09 

70 
74 

1 

S4 

S5      911 

to     to 

S9      94 

Ovtr 
95 

In  studying  this  chart  it  should  be  remembered 


The  Prognosis  of  Tuberculosis  155 

that  the  sexes  are,  in  our  population,  not  quite  equal 
numerically,  the  census  of  1900  having  shown  that 
there  are  51.2  per  cent,  of  males  and  48.8  per  cent, 
of  females. 

If  50  per  cent,  of  all  the  people  have  tuberculosis 
some  time,  and  1 1  per  cent,  of  all  people  die  of  the 
disease,  that  would  make  22  per  cent,  of  all  tul)ercu- 
lous  cases  to  die,  and  78  per  cent,  to  fail  to  die  of  the 
disease.  Of  these  last,  a  part  recover,  to  die  of 
something  else;  and  a  part,  failing  to  recover  com- 
pletely from  the  tuberculosis,  are  still  carried  off 
by  intercurrent  diseases.  Even  on  the  basis  of  the 
false  assumption  that  the  deaths  from  all  forms  of 
tuberculosis  are  14  per  cent,  of  all  deaths,  or  28 
per  cent,  of  all  cases  of  tuberculosis,  (i.  e.,  on  the 
basis  of  a  morbidity  of  the  disease  of  50  per  cent.), 
then  y2  per  cent,  of  all  the  tuberculous  patients  fail 
to  die  directly  of  this  disease.  And  this  is  a  re- 
markable showing  in  recoveries  from  a  disease  that 
many  of  the  people  —  most  of  them  in  certain  quar- 
ters —  have  regarded  as  practically  incurable. 

It  is  impossible  to  say  what  proportion  of  the 
lung  cases  actually  recover,  but  it  is  manifestly  much 
larger  than  was  formerly  supposed.  Probably  few 
recover  so  completely  as  to  have  all  the  bacilli  de- 
stroyed in  the  body  by  and  in  the  healing  process. 
Many  recover  by  healing  and  encystment  of  the 
tuberculous  area  and  products,  including  the  liacilli, 


156         •  Tuberculosis 

to  die  of  other  diseases.  What  the  proportion  is 
cannot  be  known  exactly ;  reports  and  estimates 
differ,  and  many  of  these  are  unreliable. 

It  is  probably  safe  to  say  that  the  recoveries  from 
known  lung  tuberculosis  amount  to  33  per  cent,  or 
over.  If  we  are  to  generalize  from  the  post-mortem 
and  dissection  records  already  quoted,  the  percentage 
would  be  much  above  this  figure;  counting  all  the 
hidden  and  unrecognized  cases,  the  figure  would 
probably  reach  50  per  cent. 

Of  the  cases  of  tuberculosis  of  skin,  bones,  joints, 
glands,  serous  membranes,  and  encysted  nodules  in 
various  parts  of  the  body,  a  very  large  proportion 
recover.  When  the  disease  attacks  the  cerebral  me- 
ninges, death  is  practically  certain ;  yet  Hektoen  has 
reported  one  post-mortem  study  that  shov.ed  a  per- 
fect recovery  over  small  areas  of  a  tuberculous  men- 
ingitis. The  disease  continued  to  spread  and  so  the 
patient  succumbed;  but  the  fact  that  healing  has 
been  shown  to  occur  over  any  part  of  the  affected 
tissues  in  this  disease  gives  hope  that  occasionally 
a  perfect  recovery  may  take  place. 

The  prognosis  in  individual  cases  depends  on 
circumstances.  These  are — (a)  hereditary  influ- 
ences, which  means  inborn  resisting  power  to  the 
disease;  (b)  the  actual  resisting  power,  as  shown 
by  the  history  of  the  case,  in  the  ability  (i)  to  limit 
the  lesion  by  the  process  of  fibrosis;    (2)  to  avoid 


The  Prognosis  oi  Tuberculosis  157 

pus  infection  and  therefore  fever  —  which  means 
the  abihty  to  keep  the  disease  from  burrowing 
deeply  and  away  from  channels  of  exit  fcM-  the  prod- 
ucts of  the  disease  process;  (3)  to  keep  up  body 
nutrition  and  avoid  emaciation;  (4)  to  maintain 
secretions  and  excretions;  (5)  in  women,  to  con- 
tinue menstruation;  and  (6)  to  avoid  physical  and 
physiologic  calamities,  such  as  overdoings,  accidents, 
colds,  fevers,  complications,  and  pregnancies.  H 
the  show^ing  in  these  several  ways  is  good,  so  is  the 
prognosis.  If  the  power  in  these  directions  is  low 
and  the  success  poor,  then  the  prognosis  is  bad. 
Most  cases  die  that  lack  enough  stamina  of  the 
kind  that  resists  tuberculosis  to  recover  under  rest 
and  the  best  hygiene.  All  complications  and  other 
diseases  (as  of  heart,  kidneys,  digestive  organs,  and 
blood-making  functions)  add  greatly  to  the  gravity 
of  any  case.  So  do  the  burdens  of  the  ordinary 
business  of  life. 

There  are  certain  physiologic  peculiarities  that 
stamp  people  as  probably  deficient  in  normal  resist- 
ing power  to  tuberculosis.  Among  these  may  be 
named  :  a  fastidious  appetite ;  distaste  for  meat  — 
especially  for  fat  meat  —  and  other  articles  of  the 
common  diet  of  mankind ;  inability  to  take  stimu- 
lants, when  properly  diluted,  without  signs  of  gas- 
tric or  cerebral  disturbance  from  small  doses. 

The  rate  of  progress  of  pulmonary  tuberculosis 


1 58  Tuberculosis 

toward  either  recovery  or  the  opposite  varies  with 
the  cases.  No  two  are  ahke.  The  disease  is  essen- 
tially a  long  one.  A  few  cases  of  so-called  "  gal- 
loping consumption  "  run  a  rapid  course  and  ter- 
minate in  death  in  a  few  months;  some  of  them 
seem  to  terminate  in  a  few  weeks,  but  nearly  all 
such  have  had  a  longer  duration  than  has  been  sup- 
posed. They  ha\e  perhaps  been  progressing  in  a 
slow  way  for  months  before  the  nature  of  the  dis- 
ease was  discovered;  then  this  has  spread  rapidly 
and  gone  on  to  a  fatal  issue  in  a  few  weeks. 

Patients  are  sometimes  so  little  disturbed  in  health 
by  the  disease  as  to  go  on  with  their  ordinary  voca- 
tions for  years  with  hardly  a  symptom  beyond  a 
trifling  cough  occasionally  for  a  few  days  at  a  time. 
When  these  exacerbations  occur,  they  suppose  them- 
selves to  have  taken  slight  colds.  Even  then  the 
expectoration  is  sometimes  slight ;  but  there  is  nearly 
always  some  degree  of  shortness  of  breath  that 
shows  on  running,  especially  running  up  stairs. 
This  last  may  be  so  slight  and  may  have  come  on 
so  gradually  as  to  escape  the  notice  of  the  patient, 
unless  his  attention  is  fixed  sharply  upon  it. 

I  have  known  men  acti\'ely  engaged  in  business 
and  given  to  sports  considerably  athletic,  who  have 
carried  tuberculosis  in  a  single  side  for  ten  or  fifteen 
years,  as  shown  by  repeated  findings  of  bacilli,  and 
who  have  passed  in  the  community  as  well  people 


The  Prognosis  of  Tuberculosis  159 

all  the  time.  Their  looks  indicated  normal,  even 
superior  vigor ;  they  had  only  slight  inconveniences, 
and  these  consisted  of  a  trifling  cough  occasionally, 
and  perhaps  some  moderate  annoyance  from  chron- 
ically irritated  joints.  I  have  known  a  woman  with 
tuberculosis  of  one  lung,  often  free  expectoration  of 
bloody  muco-pus,  and  occasionally  fever,  to  main- 
tain apparently  unimpaired  health  for  ten  years,  and 
in  the  mean  time  bear  two  children,  each  of  which 
she  nourished  during  a  part  of  the  nursing  period. 
But,  of  course,  in  such  cases  ph3^sical  examinations 
always  reveal  slowly  progressive  fibrosis  of  the  af- 
fected lung,  and  some  contraction  of  it  as  shown  by 
circumference  measure. 

During  the  exacerbations,  too  —  the  periods  of 
the  "  colds  " —  there  is  often  daily  elevation  of  tem- 
perature to  the  extent  of  a  quarter  to  half  a  degree; 
but  in  the  intervals,  which  often  extend  to  many 
weeks,  there  is  normal  temperature  at  all  hours  of 
the  day.  In  such  cases  the  tuberculosis  is  mostly 
confined  to  the  bronchi  and  peribronchial  tissues, 
where  the  irritation  of  the  disease  always  provokes 
the  formation  of  fibroid  tissue  to  cause  thickening 
and  contraction.  There  is  no  tendency  to  the  forma- 
tion of  suppurative  foci  outside  the  bronchi,  the  prod- 
ucts of  which  would  be  unable  to  find  exit  through 
the  tubes,  but  would  be  absorbed  into  the  blood  and 
produce  fever. 


i6o  Tuberculosis 

It  is  a  general  truth  that  of  those  forms  of  pul- 
monary tuberculosis  that  do  not  produce  fe\'er,  the 
prognosis  is  relatively  good.  Persistent  high  fever, 
with  or  without  much  pus  discharge  externally, 
means  a  bad  prognosis.  The  prognosis  is  bad, 
too.  where  there  is  little  fever,  cough,  or  expectora- 
tion, but  where  there  is  progressive  emaciation  and 
dyspnea,  with  no  dulness  on  percussion  or  bronchial 
breathing  and  with  diminishing  true  respiratory 
murmur.  Such  cases  are  of  the  dissolving  type, 
where  the  lung-substance  slowly  disappears  by  dis- 
seminated ulceration  of  the  vesicular  tissue.  The 
cases  that  promise  most  for  resistance  are  those 
where  fibrosis  occurs  in  mass  around  the  tubercu- 
lous focus,  and  this  always  shows  itself  by  bronchial 
breathing  and  some  dulness  on  percussion.  Exces- 
sive general  fibrosis  of  both  lungs,  however,  makes 
the  prognosis  ultimately  bad,  since  it  is  almost  sure 
to  increase  slowly  until  it  chokes  the  blood-supply 
to  the  parts  concerned  in  respiration,  causing  thereby 
dissolution  of  air-vesicle  walls,  and  so  finally  wear- 
ing out  the  patient. 


CHAPTER  X 

THE   PROPHYLAXIS   OF  TUBERCULOSIS 

Prophylaxis  of  tuberculosis  is  next  in  impor- 
tance to  the  treatment  of  it.  There  is  hardly  any 
ground  for  hope  that  tuberculosis  can  ever  be  wholly 
extirpated  as  a  disease  of  mankind.  But  there  is 
much  that  can  be  done  to  reduce  the  number  of 
cases;  and  danger  to  life  from  the  disease  will  be 
lessened  somewhat  l)y  measures  that  tend  to  decrease 
the  cases.  If  it  is  true,  as  it  probably  is,  that  most 
of  the  bacilli  with  which  human  l^eings  are  infected 
come  from  the  bodies  of  people,  then  measures  to 
lessen  the  number  of  them  at  large  must  be  potent 
in  reducing  the  danger  of  infection.  This  is  the 
direction  in  which  we  can  do  most  good,  and  in  this 
way  we  should  make  constant  and  strenuous  war 
against  the  disease. 

To  reduce  the  number  of  bacilli  in  the  air  is  a 
cardinal  necessity,  and  to  reduce  them  in  the  food 
and  drink  is  important.  Much  can  be  done  by  pa- 
tience and  insistence  in  the  destruction  of  sputum. 
The  sputum  can  be  easily  destroyed  by  heat  or  chem- 
icals (carbolic  or  bichloride  solutions),  and  most 
of  it  can  be  caught  in  spit-receptacles,  which  should 
always  be  within   reach   of  the  patient's  hand,   so 

i6i 
II 


1 62  Tuberculosis 

that  it  may  be  destroyed.  These  are  to  some  degree 
attainable  measures.  We  can  insist  that  tubercu- 
lous patients  shall  care  for  their  expectoration  in 
some  way  to  prevent  it  from  becoming  a  part  of  the 
dust  of  the  air.  It  will  require  constant  watchful- 
ness, often  some  severity,  and  a  good  deal  of  mis- 
sionary work  to  create  a  public  sentiment  that  will 
demand  it,  but  it  can  be  done  —  and  without  actual 
hardship  to  the  sick. 

The  body-  and  bed-clothing  used  by  patients  ought 
to  be  disinfected  from  time  to  time  by  the  heat  of 
boiling  water  or  of  an  oven  or  b}^  chemicals  —  as 
formaldehyd  gas  or  wetting  with  i  :  500  corrosive 
sublimate  solution.  Keeping  clothes  in  chests  or 
closets  strong  wnth  formalin  is  a  good  way,  or  ex- 
posure to  many  hours  of  intense  sunshine.  This  is 
a  precaution  that  is  rarely  taken,  but  ought  to  be 
whenever  a  patient  has  a  cough  of  an  intense  char- 
acter and  rather  fluid  sputum,  for  then  small  par- 
ticles of  it  are  sure  to  be  ejected  upon  the  clothing. 
Patients  should  be  discouraged  from  wearing  beards, 
particularly  mustaches,  and  from  the  use  of  utensils 
in  common  with  other  people.  This  last  is  a  means 
of  distributing  the  bacilli  occasionally.  Init  I  l)elieve 
not  often.  Nor  do  I  think  that  the  kissing  of  con- 
sumptives is  a  frequent  means  of  transmitting  the 
disease.  But  there  is  no  (lou1)t  that  projectile  cough 
is  a  common  method  of  disseminating  the  bacilli. 


The  Prophylaxis  of  Tuberculosis  163 

Those  patients  who  have  what  is  known  as  a  hard, 
dry  cough  often  project  minute  particles  of  bacilli 
containing  phlegm  three  of  four  feet  into  the  air, 
without  their  knowledge  or  suspicion.  These  parti- 
cles, when  dry,  are  more  or  less  ground  into  dust 
by  the  movements  of  the  garments,  to  be  perhaps 
inhaled  by  others.  Patients  may  be  urged  to  hold 
a  cloth  before  their  faces  while  coughing  in  that 
manner,  but  most  of  them  will  forget,  become  heed- 
less, or  disbelieve  in  the  need  of  it,  or  even  refuse 
to  try  the  measure. 

Most  people  will  not,  except  in  sanatoria,  have 
their  body-clothing  disinfected  from  time  to  time, 
so  that  dried  sputum  contaminating  it  shall  be  de- 
stroyed. The  average  person  in  private  life  will 
not  do  this,  even  if  you  implore  him  to.  Nor  is 
the  measure  perfectly  effective  to  protect  others 
from  the  bacilli  lodging  on  the  clothing.  In  order 
to  be  a  perfect  safeguard,  the  clothing  would  need 
to  be  disinfected  daily  —  and  probably  that  is  a  de- 
gree of  scrupulosity  that  we  can  hardly  expect  pa- 
tients and  care-takers  to  attain.  The  melancholy 
rule  in  vogue  is,  both  in  [irivate  practice  and  in 
hospitals,  never  to  disinfect  the  outer  clothing  at 
all ;  probal)ly  not  two  per  cent,  of  tlie  patients  ever 
have  this  service  done  for  them,  yet  it  ought  to  be 
done  for  every  one  of  them,  it  is  most  needful 
for  the  patients  who  are  housed,  and  for  all  patients 


164  Tuberculosis 

ill  cloudy  weather.  Those  who  are  much  in  the 
sunshine  have  l)y  that  inlluence  (jiiite  an  effective 
disinfection  of  all  the  outer  garments.  If  clothing 
can  receive  no  other  disinfecting  agency  it  may  usu- 
ally without  much  troul)le  be  exposed  to  the  bright 
sunshine,  and  not  less  than  this  should  be  done. 

Something  can  be  done  toward  the  destruction 
of  sputum  by  legal  steps  against  spitting  in  public 
places.  But  ordinances  against  spitting  on  side- 
walks are  not  so  useful  as  has  been  supposed.  If 
women  would  always  wear  short  dresses,  never 
gowns  that  sweep  the  ground,  and  if  we  could  avoid 
treading  upon  the  sputum,  I  am  sure  that,  aside 
from  esthetic  reasons,  it  would  be  better  to  allow 
spitting  on  the  sidewalks  rather  than  in  the  streets, 
for  on  the  sidewalks  the  sputum  receives  more  direct 
sunshine  which  may  destroy  the  bacilli,  while  in 
the  streets  it  gets  rolled  in  dust  that  impedes  the 
sun's  rays,  and  so  the  bacilli  persist  longer  and 
become  more  readily  diffused  through  the  air.  Of 
course,  every  legal  restriction  should  be  sought  to 
prevent  people  from  spitting  in  street  and  railway 
cars  and  in  all  public  conveyances,  and  in  such 
places  as  public  halls  and  lobbies.  But  ordinances 
will  not  execute  themselves,  and  if  they  arc  ever  to 
do  the  pul)lic  any  large  amount  of  good,  some  one 
must  assume  the  unpleasant  duty  of  prosecuting 
offenders.     This  is  a  task  that  everybody  shirks. 


The  Prophylaxis  of  Tul^erculosis  165 

Some  special  instruction  should  be  early  given 
to  every  patient  as  to  the  care  of  his  sputum.  If 
he  expectorates  infrequently,  and  can  to  some  extent 
control  the  function,  he  may  always  find  a  cuspidore 
with  water  or  other  safe  place  of  deposit  for  the 
sputum.  But  if  the  cough  is  frequent  and  the  dis- 
charge uncontrollable,  he  should  always  have  some 
spit-receptacle  upon  his  person  or  within  his  reach, 
and  should  use  it  with  absolute  constancy  for  every 
particle  of  tangible  sputum.  The  receptacle  must 
be  destroyed,  or  emptied,  cleansed,  and  disinfected, 
every  day  or  several  times  a  day,  with  the  certainty 
and  precision  of  clockwork.  In  no  case  should  the 
expectoration  be  swallowed  —  nor  should  a  hand- 
kerchief be  used  for  a  receptacle;  this  breeds  care- 
lessness and  a  spread  of  the  bacilli,  for  usually  the 
patients  do  not  promptly  and  fully  disinfect  their 
handkerchiefs  thus  polluted. 

There  are  numerous  hand  and  pocket  spit-cups 
on  the  market  for  tuberculous  patients,  some  of 
them  simple  and  ingenious,  others  ingenious  and 
complicated.  Patients  differ  in  the  ease  and  skill 
with  which  they  use  these  utensils.  The  test  is. 
of  course,  effectiveness.  No  cup  should  be  used 
that  breeds  carelessness  or  that  fails  to  catch  and 
hold  com])lctely  and  neatly  all  the  tangible  sputum. 

One  of  the  Ijest  devices  of  all  is  an  ordinary  news- 
paper folded  many  times,  and  the  folds  cut  out  on 


1 66  Tuberculosis 

all  sides  but  one,  so  as  to  make  a  rude  book,  between 
the  leaves  of  which  the  patient  spits.  He  can  safely 
carry  it  in  his  pocket,  to  be  burned  at  the  proper 
time,  and  can  have  a  new  one  several  times  a  day 
if  necessary. 

Another  proi)er  scheme  is  to  have  a  pocketful  of 
pieces  of  soft  cloth  or  paper  to  be  used  for  the 
sputum  and  to  be  stuffed  into  a  paper-bag  as  soon 
as  contaminated,  the  bag  and  its  contents  to  be  dul)- 
burned.  But  the  habit  of  putting  these  polluted 
cloths  or  papers  into  a  pocket  of  the  clothes,  or  the 
saving  of  the  bag  for  continuous  use  —  even  a  bag 
of  oil  silk  —  is  unsafe  or  actually  vicious  and  ought 
not  to  be  countenanced. 

Rooms  in  which  ])eop1e  die  of  tuberculosis,  and 
where  it  is  not  certain  that  the  greatest  care  has 
been  used  to  keep  them  from  being  contaminated, 
should  be  disinfected  with  sulphur  or  formalin. 
Such  contaminated  rooms  doul)tless  often  spread  the 
disease.  x\nd  I  believe  that  it  is  best  to  have  local 
health  officers  required  as  a  matter  of  routine  duty, 
when  a  case  is  reported  of  death  from  tuberculosis, 
to  investigate  the  premises,  and  if  they  find  reason 
to  believe  there  has  Ijeen  carelessness  in  the  care  of 
the  patient,  to  insist  upon  disinfecting  the  rooms. 
Such  a  procedure,  discreetly  carried  out,  would  prol)- 
ably  arouse  very  little  anatgonism  on  the  part  of  the 
public,  while  it   would  do  a  great  deal  of  good. 


The  Prophylaxis  of  Tuberculosis  167 

The  best  way  to  disinfect  a  room  is  probably  by 
the  very  thorough  use  of  formaldehyd  gas,  dis- 
charged by  evaporating  formalin  over  a  fire  or  lamp, 
a  pint  being  used  to  a  room  of  100  square  feet  of 
floor  space;  or  by  some  other  apparatus  that  will 
discharge  the  pure  gas  into  the  room.  The  formalin 
is  often  evaporated  from  hanging  sheets,  but  this 
is  less  efifecti\'e.  The  rooms  should  be  closed  and 
sealed  during  the  process,  and  not  be  opened  for 
twenty-four  hours.  Rooms  may  be  purified  nearly 
or  quite  as  well  by  washing  floors,  woodwork,  walls, 
and  ceilings  with  a  rather  strong  solution  of  cor- 
rosive sublimate,  say  i  :  1000  or  even  i  :  500.  The 
surfaces  do  not  need  to  be  rubbed  with  the  solution, 
but  simply  wetted,  and  they  may  be  wiped  dry  in 
five  minutes,  after  which  the  rooms  are  ready  for 
use  again. 

Another  prophylactic  measure  that  has  been  at- 
tempted in  a  few  cities,  and  one  that  would  do  much 
good  if  it  could  be  carried  out,  is  a  requirement  that 
physicians  shall  report  to  the  Health  Department 
all  cases  of  tuberculosis,  exactly  as  they  do  cases 
of  scarlet  fever,  diphtheria,  small-pox,  and  other 
contagious  diseases.  Tuberculosis  is  in  a  way  con- 
tagious; scarlet  fe\er  is,  but  differently,  and  many 
physicians  claim  that  the  two  diseases  should  be 
dealt  with  in  the  same  way.  If  health  ofiicers  knew 
where  all  the  cases  of  tulicrculnsis  arc.  they  might 


1 68  Tuberculosis 

exercise  some  wholesome  repressive  influence  over 
the  distribution  of  the  disease.  lUit  they  cannot 
know  of  all  the  cases,  nor  half  of  them,  and  the 
people  are  probably  not  sufficiently  advanced,  or 
used  to  official  supervision  at  present,  to  submit  to 
such  a  rule  unless  very  discreetly  administered. 
Some  few  cities  have  adopted  the  regulation,  but 
it  has  so  far  never  been  effective.  Both  public 
and  profession  disregard  it  to  a  large  degree.  Many 
physicians  fail  to  report  their  cases  frankly ;  they 
forget,  perhaps  wittingly,  to  make  a  diagnosis,  or 
call  their  tuberculous  cases  by  some  other  name; 
and  the  people  are  ready  to  connive  at  such  a  course. 

This  is  hardly  to  be  wondered  at.  A  disease  that 
at  some  time  in  their  lives  attacks  at  least  half  of  all 
the  people,  and  makes  a  large  percentage  of  these 
its  victims ;  that  often  permits  them  to  go  about 
and  appear  to  have  only  a  simple  cold  or  to  be  merely 
a  little  depressed  or  debilitated,  and  that  has  a  range 
of  duration  from  a  few  weeks  to  forty  years,  cannot 
be  regulated  by  law  as  scarlet  fever,  small-pox,  and 
diphtheria  are.  These  diseases  come  on  and  termi- 
nate rapidly,  and  much  is  done  to  limit  the  spread 
of  them  by  current  methods  of  prompt  legal  iden- 
tification, so  that  the  people  readily  acquiesce ;  but 
tuberculosis  offers  in  many  particulars  a  different 
problem  and  requires  different  dealing. 

Probably  the  time  will  come  when  in  many  com- 


The  Prophylaxis  of  Tuljerculosis  169 

munities  most  of  the  cases  of  tuberculosis  will  be 
reported ;  but  a  large  measure  of  delicate  and  con- 
siderate discretion  will  need  to  be  exercised  by  health 
officers  in  order  to  make  it  possible.  If  such  a  meas- 
ure could  be  thoroughly  carried  out,  it  might  be  of 
great  assistance  to  the  public  in  preventing  the 
spread  of  the  disease  through  the  dissemination  of 
the  bacilli.  This  is  almost  the  sole  way  in  which 
the  disease  can  be  limited,  and  this  benefit  must 
for  a  long  time  to  come  be  expected  —  and  needs 
be  sought  —  mainly  through  the  efforts  of  physicians 
and  the  enlightened  sense  of  the  general  public  rather 
than  by  attempted  official  regulation. 

There  is  another  direction  in  which  we  can  do 
something  toward  preventing  the  spread  of  tuber- 
culosis. That  is  by  discouraging  the  use  of  carpets 
and  the  sweeping  of  rugs  in  houses.  Rugs  should 
never  be  swept  as  they  lie  on  the  floor,  and  carpets 
are  a  hygienic  abomination ;  they  fill  the  air  with  dust 
and  pollution  of  many  sorts,  and  undoubtedly  spread 
tuberculosis.  A  housemaid  will  cover  and  iM"otect 
her  hair  while  sweeping  them,  but  will  breathe  the 
dust  and  filth  into  her  lungs. 

We  can  reduce  the  tubercle  bacilli  in  food.  The 
only  foods  likely  to  cause  the  disease  in  people  are 
meat  and  milk.  If  meat  is  cooked  it  cannot  transmit 
the  disease,  for  a  temperature  of  180°  F.  destroys 
the  bacilli.     We  naturally  object  on  esthetic  grounds 


1 70  Tuberculosis 

to  eating  the  meat  of  tuberculous  animals,  but  if  it 
is  well  cooked,  no  harm  can  result  to  the  health  of 
consumers.  Alany  States  require  by  law  the  de- 
struction of  tuberculous  cattle,  as  these  are  the  only 
animals  that  can  l)e  to  any  considerable  degree,  if 
indeed  they  are,  a  menace  to  mankind  in  this  direc- 
tion. Such  laws  are  both  good  and  l)ad :  good 
because  seriously  sick  animals  should  be  slaughtered; 
bad  if  the  execution  of  the  laws  is  so  literal  and 
sweeping  as  to  sacrifice  a  great  amount  of  property 
that  does  no  harm  to  any  one.  This  latter  has  been 
done  in  certain  States,  causing  unnecessary  burdens 
to  the  taxpayers  who  have  had  to  pay  for  the  slaugh- 
tered animals.  As  a  result,  some  of  the  laAvs  have 
been  repealed. 

Professor  Russell  of  the  I'niversity  of  Wisconsin 
has  demonstrated  that  there  is  no  need  of  destroying 
all  tuberculous  cattle.  An  animal  slightly  sick,  and 
put  under  hygienic  conditions,  will  ofter  recover; 
its  lung  lesions  will  become  encysted,  as  those  of 
man  often  arc,  and  it  will  be  well  except  for  the 
scars  remaining  after  the  disease.  And  it  is  a  ques- 
tion whether  we  should  be  squeamish  about  a  food 
animal  that  looks  well,  but  in  which  a  few  bacilli  are 
found  (in  non-food  p.arts  chiefly),  when  the  meat 
is  cooked  and  eaten  by  people  one-half  of  whom 
have  bacilli  somewhere  in  their  own  bodies.  Calves 
of  tuberculous  cows,  if  prevented  from  taking  their 


The  Prophylaxis  of  Tuberculosis  171 

mother's  milk  until  it  has  been  pasteurised,  may 
subsist  upon  it  without  acquiring  the  disease.  It 
is  better  and  easier  to  take  care  of  cattle  than  of 
people,  and  there  is  more  hope  of  recovery  for  them. 
In  the  next  few  years  the  laws  directed  against  tu- 
berculous cattle  in  this  country  will  probably  be 
modified  so  that  animals  that  are  manifestly  sick 
will  be  destroyed  at  public  expense,  and  the  healthy 
looking  ones,  even  if  they  do  react  slightly  to  tuber- 
culin, may  be  kept,  if  people  will  house  and  care 
for  them. 

The  laws  ought  to  require  the  State  to  exercise 
some  supervision  over  herds  that  are  even  slightly 
infected  with  tuberculosis,  in  order  to  prevent  the 
spread  of  the  disease.  But  it  is  more  important  to 
supervise  the  dairies,  and  to  prevent  the  distributi(Mi 
of  milk  that  is  out  of  condition  or  is  below  standard, 
than  to  supervise  the  meat  that  goes  into  private 
houses.  Here  is  a  direction  in  which  physicians 
can  do  a  useful  service.  Dairies  selling  milk  to  the 
public  should  be  inspected  frequently,  and  all  sick 
cows  eliminated  in  some  way.  If  they  react  to 
tuberculin  in  the  slightest  degree,  their  milk  should 
never  be  sold  to  the  public.  But  it  may  l)e  pasteur- 
ized and  used  as  food  for  pigs  or  calves  without 
harm  to  any1)ody.  The  danger  of  tuberculous  cows' 
milk  carrying  the  disease  to  the  intestinal  canal  of 
children  is  shown  by  recent  studies  by  Koch  to  be 


172  Tuberculosis 

greatly  overrated.  By  his  estimate,  based  on  great 
numbers  of  careful  post-mortems,  the  children  who 
have  primary  tuberculosis  of  the  intestines  are  not 
one  per  cent,  of  the  whole  numljer  dying  of  tuber- 
culosis. This  goes  far  to  prove  that  children  rarely 
take  the  disease  from  infected  milk.  Nevertheless, 
the  selling  of  tuberculous  milk  should  be  made  a 
crime  l)y  law. 

How  may  an  individual  avoid  acquiring  tubercu- 
losis? Direct  infection  needs  only  to  be  mentioned. 
One  should  avoid  getting  tul)erculous  sputum  or 
other  bacilli  carriers  on  the  hands  or  on  excoriated 
surfaces  of  the  body,  and  avoid  going  into  great 
accumulations  of  bacilli.  One  probably  cannot  es- 
cape the  bacilli  altogether  in  towns  and  cities  any- 
where in  the  world,  but  he  may  avoid  going  where 
they  are  \ery  numerous  and  where  there  is  evidence 
that  they  are  thick  in  the  dust  of  the  air.  As  al- 
ready said,  it  is  less  a  question  of  who  gets  bacilli 
into  his  system  than  of  who  fails  to  resist  them. 
Almost  anyone  can  probably  resist  a  few  on  his 
mucous  surfaces,  but  scarcely  anyone  who  takes 
in  a  swarm  of  them. 

There  is  no  need  of  fearing  the  tuberculous  pa- 
tient if  he  is  well  cared  for  —  the  thoughtful  and 
considerate  ])atient  who  knows  he  is  tuberculous. 
It  is,  in  my  judgment,  a  great  wrong  both  to  indi- 
viduals and  to  the  community  to  keep  such  patients 


The  Prophylaxis  of  Tuberculosis  173 

in  ignorance  of  their  true  condition.  With  ver)' 
few  exceptions,  patients  with  tuberculosis  should 
know  the  fact.  It  terrilies  them  less  to  know  it 
than  it  does  their  friends;  and  if  they  know  how 
they  may  constantly  put  their  neighbors  in  peril, 
they  will  usually  be  careful.  In  many  health  re- 
sorts people  refuse  to  take  such  patients  to  board, 
even  if  they  are  known  to  be  scrupulous  in  the  man- 
agement of  their  sputum  and  to  follow  all  the  pre- 
scribed regimen.  This  fear  is  really  groundless  if 
the  patients  are  careful ;  but  to  be  careful  is  to  de- 
stroy all  sputum  and  even  to  disinfect  regularly,  by 
sunlight  or  otherwise,  all  outer  clothing,  so  as  to 
prevent  the  minute  particles  of  sputum  ejected  in 
coughing,  and  lodging  on  the  clothes,  from  con- 
taminating the  air.  Nurses  of  consumptives,  if  care- 
ful of  their  patients  and  careful  of  themselves, 
rarely  take  the  disease  unless  they  become  reduced 
in  health.^ 

To  a^•oid  tuberculosis  one  should  keep  himself 
well,  even  vigorous,  and  do  those  things  that  tend 
to  keep  his  body  in  a  normal  condition.  The  fault 
of  most  of  us  is  that  we  do  not  keep  in  a  normal 
condition ;    we  work  too  much,  have  bad  digestion, 

iThe  experience  of  the  Chicago  Hospital  for  Consumptives 
under  Dr.  Wood  is  instructive.  So  great  was  the  scrupulosity 
in  the  care  of  the  sputum,  that,  after  a  continuous  occupancy 
of  the  building  by  an  average  of  100  patients  for  over  two 
years,  it  was  impossible  to  demonstrate  bacilli  in  the  dust 
gathered   from  the  wards. 


174  Tuberculosis 

pay  too  little  attention  to  ventilation,  are  housed 
too  much  —  are  too  little  in  the  great  out-of-doors. 
Then  we  are,  many  of  us,  foolish  enough  to  believe 
that  if  we  exercise  greatly  and  become  athletes  we 
shall  escape  the  disease.  It  is  almost  as  much  a 
risk  to  carry  the  system  above  a  normal  condition 
of  muscular  vigor  as  it  is  to  allow  it  to  fall  below. 
Excesses  of  all  sorts  predispose  to  tuberculosis. 

The  kind  of  lives  that  many  young  people  lead 
predisposes  to  the  disease.  I  mean  lives  of  spon- 
taneity. If  they  enjoy  work,  they  overdo  it  and 
go  without  sleep;  they  neglect  disturbances  of  di- 
gestion, neglect  constipation,  and  they  stimulate  — 
because  they  like  stimulants  or  because  they  are  in- 
vited to  take  them.  As  a  result,  they  live  much 
of  the  time  below  tlieir  proper  physiologic  standard. 
Considering  these  circumstances,  it  is  no  wonder 
that  tuberculosis  is  as  prevalent  as  it  is  among  the 
young. 

Wherever  careful  and  systematic  measures  have 
been  consistently  carried  out  toward  prophylaxis, 
they  have  succeeded  to  a  most  encouraging  degree. 
The  records  of  many  cities  show  this,  and  they 
will  hereafter  show  it  more.  But  these  benefits  have 
come  mainly  through  the  lessening  of  the  bacilli  in 
the  air,  not  so  much  from  any  improvement  in  the 
habits  of  the  public.  People  who  are  careful  of 
their  health  and  see  to  it  that  they  keep  steadily 


The  Prophylaxis  of  Tuberculosis  175 

in  good  vigor  are  more  hkely  to  avoid  the  disease; 
and  the  people  who  need  to  learn  this  lesson  belong  to 
all  ages  of  the  activity  of  human  life.  The  cardinal 
doctrines,  to  be  emphasized  at  all  times,  are :  Keep 
well  and  normally  strong;  always  breathe  the  best 
and  cleanest  air;  and  avoid  the  bacilli  of  tubercu- 
losis —  not  by  making  pariahs  of  the  sick,  but  by 
a  never-ending  wise  campaign  for  the  destruction 
of  these  microbes. 

It  is  easy  to  say  what  precautions  may  limit  the 
spread  of  tuberculosis.  They  all  have  for  their 
chief  object  the  limitation  of  the  bacilli,  mostly  in 
the  air;  but  the  difficulty  comes  in  trying  to  have 
them  enforced.  And  there  are  many  patients,  mostly 
among  the  poor  and  ignorant,  who  never  will,  in 
their  own  homes  if  they  have  such,  or  wandering 
from  place  to  place,  carry  out  any  measures  of 
caution.  There  is  only  one  way  to  prevent  them 
from  daily  spreading  the  contagion,  and  that  is  to 
segregate  them  from  the  rest  of  the  coninmnity  in 
sanatoria  at  public  expense.  That  this  will  some 
time  be  done  to  a  very  large  extent  I  have  no  doubt 
whatever.  Several  States  are  already  moving  in 
this  direction,  and  others  will  follow.^  Nor  will 
it  in  the  end  be  any  special  burden  to  the  State, 
for  this  precautionary  step,  l)y  lessening  the  disease 

1  Massachusetts  already  has  maintained  one  such  sana- 
torium for  some  time,  to  the  great  satisfaction  of  both  pro- 
fession and   public. 


176  Tuberculosis 

in  the  community,  is  sure  to  prevent  other  losses 
that  are  vastly  greater  in  a  pecuniary  way  than  the 
cost  of  the  sanatoria. 

In  a  sanatorium  it  is  possible  to  control  irrespon- 
sible and  careless  people  and  make  them  mindful  of 
their  habits  and  the  harm  they  are  liable  to  bring 
to  others.  It  is  not  possible  to  do  these  things 
anvwhere  else. 


CHAPTER    XI 

TREATMENT   OF   TUBERCULOSIS.     GENERAL 
PRINCIPLES 

I  WISH  to  speak  first  of  some  general  considera- 
tions of  the  management  of  tuberculosis,  and  after- 
ward to  deal  in  more  detail  with  the  several  phases 
of  the  subject.  The  most  natural  thing  to  seek 
first  is  some  means  to  destroy  the  bacilli  of  tuber- 
culosis in  the  diseased  body,  without  serious  injury 
to  the  body.  Many  investigators  have  worked  on 
this  problem  and  numerous  experiments  have  been 
made,  but  all  to  little  effective  purpose.  No  germi- 
cide that  fills  these  conditions  has  been  found.  Pos- 
sibly some  of  the  so-called  antitoxic  animal  serums, 
some  modified  products  of  tuberculin,  and  drugs 
that  increase  the  leukocytes  of  the  blood,  like  nu- 
cleinic  acid  and  nucleins,  may  repress  the  growth 
and  spread  of  bacilli  a  little;  but  if  they  produce 
this  efifect,  it  is  not  known  whether  they  do  it  directly 
or  indirectly;  and  proof  of  anv  great  power  on  their 
part  is  wanting. 

The  chief  factor  in  tlie  recovery  of  \ictims  of 
non-surgical  tuberculosis  is  the  power  of  their  own 
physiologic  resistance.  Their  prospects  of  recovery 
are  enhanced  by  an  increase  of  this  power  and  are 
always    lessened   by  the   slightest    reduction   of   it, 

177 
12 


1/8  Tuberculosis 

and  no  measure  of  treatment  that  lowers  or  neglects 
this  power  is  entitled  to  serious  consideration.  All 
through  the  long  course  of  sickness  the  truth  is  daily 
verified,  that  any  depreciation  in  the  general  vigor 
and  resisting  power  is  followed  by  an  increase  in 
the  e\idence  of  the  disease,  while  any  manifest 
increase  of  physiologic  force  is  straightway  fol- 
lowed by  a  decrease  in  the  symptoms.  To  adopt 
any  treatment  that  neglects  or  low^ers  the  physiologic 
resisting  power,  in  the  hope  of  producing  some  mys- 
terious destruction  of  the  disease  itself,  or  its  bacilli, 
is  constructive  suicide,  if  not  constructive  homicide. 
So  far  as  w-e  know,  the  bacilli  within  the  human 
body  may  be  killed  or  imprisoned  by  the  forces  of 
the  body,  not  by  drugs  or  other  things  put  into  it. 
And  how^  to  increase  that  power  is  the  paramount 
purpose  of  treatment. 

One  of  the  great  obstacles  to  the  successful  treat- 
ment of  medical  tuberculosis  is  the  widespread  no- 
tion, both  in  and  out  of  the  profession,  that  the 
treatment  may  be  short  and  that  satisfactory  results 
may  be  attained  quickly.  The  truth  is  that  the 
disease  is  long  and  chronic,  and  that  treatment  must 
be  long  and  sustained,  and  of  such  a  character  that 
it  may  endure  and  l)e  borne  for  a  long  time. 

Unfortunately,  most  of  our  treatment  of  tubercu- 
lous patients  heretofore  has  been  haphazard,  or  based 
on  the  theory  that  there  are  only  a  few  things  that 


General  Principles  of  Treatment  179 

we  can  do  for  them.  One  of  these  is  to  send  them 
to  a  climate  for  consumptives,  and  another  is  to  keep 
them  at  home  and  prescribe  drugs,  chiefly  such  as 
cod-liver  oil  and  guaiacol  or  creasote.  With  these 
patients  we  should  least  of  all  think  that  a  particu- 
lar drug  is  of  any  great  value  against  the  disease, 
and  that  we  can  do  our  duty  by  prescribing  it.  This 
is  the  smallest  part  of  the  right  management. 

Regarding  every  patient  who  comes  to  us,  we 
should  ask  the  question  at  the  beginning  whether 
the  probabilities  are  that,  under  any  management 
whatever,  there  is  hope  of  recovery.  Of  course,  as 
to  some  cases,  when  they  first  come,  it  is  a  foregone 
conclusion  that  death  must  be  certain  and  rather 
speedy.  Take  a  patient,  for  instance,  in  the  years 
of  adolescence,  with  a  bad  family  history,  who  has 
a  large  lung  infiltration  that  has  come  on  rapidly 
with  high  fever,  and  therefore  extreme  mixed  in- 
fection. We  know  that  for  such  a  patient  there  is 
no  possible  recovery.  But  many  have  small  deposits 
developing  slowly,  and  strong  physiologic  powers; 
they  have  little  fever  and  good  digestion,  and  thus 
a  good  prospect  of  recovery. 

If  in  any  case  the  prospect  is  even  fair,  we  should 
outline  a  campaign  like  one  of  war,  for  it  is  such 
a  campaign ;  and  the  fact  that  it  is  a  long  and  not 
a  short  one  should  be  strongly  impressed  upon  the 
patient.     His  course  sliould  be  mapped  out  in  minute 


i8o  Tuberculosis 

detail,  and  l)e  put  on  paper  if  necessary.  As  it  may 
often  go  to  the  length  of  making  him  uncumfoilal)le, 
the  fact  should  Ije  impressed  upon  him  that  its  pur- 
pose is  to  save  his  life.  He  should  know  the  char- 
acter of  his  disease,  and  its  dangers.  We  may  find 
it  necessary  to  restrict  his  pleasures,  to  segregate 
him  from  his  friends  if  they  are  harmful  to  him  or 
he  to  them,  and  to  prescribe  many  things  that  are 
unpleasant.  \Yg  may  fairly  try  to  enlist  him  in  a 
long  and  perhaps  arduous  and  self-denying  cam- 
paign if  there  is  a  chance  of  saving  his  life,  and  he 
should  know  the  full  meaning  of  this  last  considera- 
tion, and  feel  it  if  he  can. 

If  there  is  little  or  no  chance  of  improvement,  we 
should  pursue  a  different  course  —  one  that  more 
concerns  the  present  comfort,  even  pleasures,  of 
the  patient ;  and  so  we  can  never  have  a  routine 
treatment  for  this  disease.  We  may,  if  it  seems  best, 
refrain  from  telling  this  patient  the  full  nature  of 
his  disease  and  his  prospects,  and  should  never  say 
that  his  case  is  hopeless;  and  we  ought  to  manage 
him  so  that  his  pleasures  will  not  be  much  inter- 
fered with,  and  will  yet  be  prex-ented  from  harming 
him  much.  Many  of  these  patients  may  be  kept 
comfortable  by  our  ministrations,  and  death  may 
come  to  them  so  slowly  and  unconsciously  that  they 
will  never  lose  hope.  They  may  plan  for  their  tem- 
poral affairs  up  to  within  a  short  time  before  or 


General  Principles  of  Treatment  i8i 

even  to  the  hour  of  death.  To  these  we  do  as  great 
a  service  —  to  their  hearts  and  minds  and  to  their 
friends  —  as  we  do  to  those  who  recover,  because 
we  make  their  sickness  as  happy  as  possible,  and 
almost  completely  painless. 

For  those  who  have  a  fair  chance  of  recovery  we 
should  plan  our  treatment  logically  and  consistently; 
and  there  are  a  few  cardinal  facts  that  must  always 
be  considered  in  every  case  of  this  sort.  The  patient 
should,  as  a  rule,  know  that  he  has  tuberculosis,  and 
know  what  the  treatment  means.  He  should  know 
his  own  danger,  and  what  danger  he  brings  to  others. 

The  first  lesson  for  him  to  learn  is  that  it  is  his 
chief  business  in  life  to  get  well  if  he  can,  and  that 
for  the  present  he  has  no  other  vital  occupation. 
Only  the  necessities  of  existence  are  an  exception. 
You  will  find  among  such  patients  business  men 
and  young  men  planning  to  engage  in  new  kinds 
of  business,  or  to  go  on  with  their  old  ones  in  their 
wonted  intensity,  when  there  is  really  no  need  for 
them  to  work,  and  they  are  able  to  devote  their 
lives  to  getting  well.  And  they  are  sometimes  eager 
to  launch  out  into  all  sorts  of  social  diversions  and 
imagined  duties.  Every  one  of  these  schemes  must^ 
1)e  demolished  if  possiljle.  You  must  charge  the 
patient  that  such  devices  are  worse  than  useless ; 
that  he  must  devote  himself  to  his  sole  duty  of  re- 
covery if  he  hopes  to  succeed. 


1 82  Tuberculosis 

The  treatment  ought  to  be  so  planned  as  to  re- 
store the  already  lowered  power  of  resistance,  and 
thus  lessen  the  lack  oi  balance  between  the  vital 
powers  of  the  patient  and  the  load  they  are  re- 
(juired  to  bear.  The  ])o\vers  that  are  below^  par 
must  be  raised;  none  will  need  to  be  l)roug"ht  down. 
Rest,  exercise,  and  tonics  may  carry  the  patient  up 
to  his  physiologic  par;  this  should  never  be  ex- 
ceeded, and  so  no  athletic  exercises  are  to  be  in- 
dulged in  beyond  the  evident  requirements  of  the 
normal  standard.  l"he  exercises  that  can  be  used 
with  propriety  are  all  gentle,  as  some  non-tiring  out- 
door occupation  like  horseback  riding,  driving,  and 
walking,  and  these  never  to  the  extent  of  increasing 
the  musculature  above  normal.  The  general  activi- 
ties of  life  must  be  reduced.  Many  a  patient  can 
recover  and  li\e  long  if  he  will  be  content  with  a 
more  moderate  speed,  when  he  would  kill  himself 
in  a  year  or  two  if  he  insisted  on  his  habitual  gait. 

The  forces  that  have  reduced  the  average  patient 
must  be  studied  and  dealt  with.  The  first  is  too  much 
work,  too  much  strain  of  some  kind.  The  natural 
remedy  for  that  is  rest,  and  for  the  fever  cases  com- 
plete and  absolute  rest.  Next  is  lack  of  sufficient 
l)erfect  and  clean  air  to  breathe.  This  is  the  com- 
mon affliction  of  nearly  all  the  people.  The  remedy 
for  this  is  obvious,  but  it  is  one  of  the  most  difficult 
remedies  to  induce  people  to  take.     The  fever  pa- 


General  Principles  of  Treatment  183 

tient  must  never  be  permitted  to  exercise  under  any 
circumstances  if  we  can  prevent  it,  and  I  wish  to 
say  this  with  all  the  force  possible. 

For  those  without  ievev  there  must  be  a  change 
in  exercise  and  occupation.  The  effect  upon  the 
human  body  of  a  change  in  activities,  work,  and 
scene  is  remarkable.  It  rests  the  tired  brain  powers 
and  the  tired  muscles,  and  puts  the  strain  on  muscles 
that  have  been  little  used  and  on  mental  powers  and 
forces  that  ha\e  been  resting  for  long.  That  is  to 
say,  it  shifts  the  load.  If  you  carry  a  heavy  load 
on  one  shoulder  until  it  is  tired,  and  can  then  shift 
it  to  the  other  shoulder,  it  rests  you  and  gives  a 
great  sense  of  relief ;  it  not  only  rests  but  it  strength- 
ens you,  and  enables  you  to  conserve  power.  The 
same  is  true  of  mental  and  nervous  experiences. 

We  are  creatures  of  custom  as  to  work  and  rest. 
We  rest  usually  one  day  in  seven,  and  work  per- 
haps eight  to  twelve  hours  out  of  the  twenty-four; 
business  and  professional  men  often  work  fifteen 
hours.  We  eat  three  times  a  day  and  sleep  about 
seven  or  eight  hours,  and  are  in  bed  a  little  over 
eight  hours.  These  are  habits  grown  out  of  experi- 
ence, and  fit  the  needs  of  the  well.  We  must  start 
out  with  the  postulate  that  all  this  ought  to  be 
changed  for  the  average  tuberculous  patient.  From 
])eing  recumbent  eight  hours  in  the  twenty-four,  he 
must  recline  twelve  or  fifteen  hours;  for  bad  cases, 


184  Tuberculosis 

the  longer  the  rest  and  the  more  complete  it  is,  the 
better.  He  must,  if  poorly  nourished,  change  his 
eating  habits  to  four  or  six  food  doses  a  day,  with 
corresponding  changes  in  his  dietary.  He  must  un- 
derstand that  he  is  not  like  a  well  person,  and  must 
have  some  rules  of  life  that  nullify  certain  of  the 
customs  of  society. 

Ordinary  house-air,  and  especially  bed-room  air, 
in\-ites  tuberculosis,  and  fosters  it  when  present.  We 
all  breathe  too  little  good  air.  The  house-air  usually 
contains  more  or  less  dust  and  bad  gases,  is  lacking 
in  oxygen,  and  contains  too  much  carbon  dioxid. 
Patients  should  breathe  air  as  free  from  dust  as 
possible,  and  constantly  outdoor  air,  or  as  near  that 
as  can  be  had;  and  the  night-air  is  the  best  of  all, 
since  it  is  the  cleanest.  Nearly  all  the  benefit  that 
comes  of  going  to  a  resort  for  consumptives  is  due 
to  the  fact  that  the  patients  are  placed  where  they 
breathe  better  and  purer  air.  A  primary  purpose  is 
to  be  much  out  of  doors,  Ijut  almost  the  sole  benefit 
from  that  comes  of  the  purity  of  the  air  breathed. 
Nor  should  the  inspired  oxygen  be  reduced  by 
breathing  through  reducers — little  mouth-tubes  that 
impede  the  outflow  or  inflow  of  air,  and  distend 
the  air-vesicles  of  the  lungs.  Moreover,  such  de\'ices 
probably  injure  the  lungs,  as  also  do  repeated  pro- 
found unimpeded  inspirations,  since  they  both  tend 
to  put  the  diseased  lung-tissue  on  the  stretch,  which 


General  Principles  of  Treatment  185 

is  almost  sure  to  do  harm.  It  is  substantially  im- 
possible that  a  severe  physical  strain  of  tuberculous 
tissue  can  ever  do  good. 

Many  of  the  patients  have  poor  nutrition,  take 
too  little  food,  and  often  of  the  wrong  kinds,  take 
it  in  the  wrong  way,  and  have  bad  digestion  almost 
constantly.  A  study  ought  to  be  made  of  each  case, 
with  a  view  to  improving  these  conditions.  How 
and  when  shall  a  patient  take  food,  that  the  best 
digestion  may  be  attained  and  the  best  use  be  made 
of  such  digestive  power  as  he  has  and  can  have? 
The  fault  usually  is  that  the  tasks  put  upon  the  di- 
gestive organs  are  too  large  and  too  few.  The 
patient  may  need  to  have  food  six  times  a  day  in- 
stead of  three,  and  the  portions  to  be  reduced  in 
size.  The  articles  of  food,  the  methods  of  orepara- 
tion,  and  the  ways  of  eating  may  be  wrong,  and 
need  to  be  changed  in  order  to  avoid  discomfort 
and  other  symptoms  of  poor  function.  The  dose  of 
food  should  be  reduced  to  the  point  where  it  will,  if 
possiljle,  l)e  well  digested,  and  the  eating-times  be 
as  frequent  as  possible  and  not  interfere  with  diges- 
tion. That  is,  the  best  use  should  be  made  of  the 
power  of  the  organs  that  make  blood;  and,  weak- 
ened as  they  are  by  the  tuberculosis,  that  power  is 
best  expended  on  small  quantities  of  food  taken  fre- 
quently. 

The  patient  may  have  a  pain  in  the  stomach  or 


1 86  Tuberculosis 

bowels,  and,  if  the  pbysician  is  not  careful,  he  will 
find  himself  prescribing  bismuth  or  some  other  quiet- 
ing drug  when  the  better  remedy  might  be  a  change 
in  the  food  or  the  dose  of  it,  in  the  method  of  cook- 
ing or  the  insalivation  of  it,  or  the  use,  perhaps,  of 
a  little  of  some  of  the  pharmaceutical  aids  to  diges- 
tion. Discomfort  in  the  bowels  may  be  due  to  in- 
digestion or  to  lack  of  drainage,  and  the  drainage 
from  the  colon  may  be  deficient,  notwithstanding 
a  loose  stool  each  day.  For  diarrhea  astringents  are 
likely  to  be  prescribed  when  perhaps  all  that  is 
needed  is  a  careful  attention  to  the  regimen.  If 
careless,  one  may  prescribe  some  physic  for  constipa- 
tion, to  be  followed  by  worse  constipation,  when  an 
enema  or  an  intestinal  tonic  might  serve  the  purpose 
and  be  followed  by  no  ill-effects. 

It  is  curious  how  the  moral  and  mental  condi- 
tions of  life,  the  daily  worries,  disturb  these  cases. 
Two  sets  of  people  may  work  side  by  side,  and  one 
set  recei\'e  a  few  cents  more  wages  a  day  than  the 
others,  li\-ing  perhaps  on  the  same  kinds  of  food, 
and  under  conditions  similar  in  every  other  respect. 
But  the  poorer-paid  set  will  have  more  sickness  than 
the  others,  and  have  less  resisting  power  when  they 
are  sick.  So  the  mental  state  of  the  patient  is  al- 
ways a  leading  factor  in  his  prospects.  Often  a 
change  of  climate  relieves  the  moral  monotony;  but 
in  advising  a  change,  if  a  physician  is  not  careful, 


General  Principles  of  Treatment  187 

he  will  toss  his  patient  from  the  frying-pan  into  the 
fire.  One  may  advise  him  to  go  off  to  a  good  cli- 
mate for  consumption,  and,  in  so  doing,  take  him 
away  from  his  friends,  their  care  and  sympathy, 
and,  no  provision  being  made  to  take  the  place  of 
these,  his  disease  may  not  only  be  unimproved,  but 
may  get  worse  because  he  is  homesick  and  unhappy. 
The  free  stimulation  in  which  your  patient  has 
perhaps  indulged,  and  excesses  of  all  kinds  that  have 
lowered  his  vitality,  must  be  corrected.  The  patient 
is  to  have  no  excess  in  his  life  whatever;  his  life 
must  be  serious  and  tranquil,  and  may  be  happy. 
If  a  young  man,  he  ought  to  live  the  life  of  a  man 
of  forty-five.  The  trouble  with  such  advice  to  young- 
people  is  that  they  are  mostly  incapable  of  the  en- 
joyment of  the  life  of  a  person  of  forty-five,  because 
they  lack  the  mental  perspective  and  capacity  for 
the  higher  pleasures.  Few  people  will  ever  have  any 
such  mental  joys  in  the  time  before  as  they  will 
after  that  age.  Youth  has  no  perspective;  it  cannot 
look  back  and  see  the  relation  of  things,  and  so  be 
able  to  weigh  them ;  and  it  frets  and  fumes  about  a 
lot  of  questions  that  it  tries  hard  to  settle.  At  forty- 
five  the  ripening  of  the  mind  is  so  much  advanced, 
and  mentrd  pleasures  are  so  much  greater,  that  one 
who  has  reached  that  age  in  serenity  is  to  be  con- 
gratulated. He  has  the  power  to  minify  the  carking 
effects  of  his  sickness. 


1 88  Tuberculosis 

We  are  apt  to  declare  that  a  person  in  health  does 
not  need  stimulation,  yet  we  all  indulge  in  it  more 
or  less.  W'e  drink  coffee  and  tea  and  use  tobacco 
(there  are  some  who  contend  that  tobacco  is  not 
a  stimulant),  and  we  take  various  forms  of  alcohol 
and  numerous  condiments.  But  the  records  of  armies 
and  life  companies  show  that  normally  healthy 
people  can  live  longer  and  endure"  more  without  than 
with  alcoholic  stimulants.  Probably  this  is  true  of 
all  stimulants.  If  a  person  with  tuberculosis  has 
been  in  the  habit  of  taking  stimulants  excessively,  he 
should  stop  the  excess  anyway,  if  not  the  hal)it  en- 
tirely. But  such  a  patient  who  has  never  had  the 
habit  will  often  find  alcoholic  stimulants  beneficial, 
if  taken  regularly  as  a  tonic  and  in  moderation.  And 
if  taken,  a  stimulant  should  be  used  with  the  same 
regularity  as  any  other  drug.  There  are  some  w'ho 
cannot  take  alcoholic  tonics  at  all ;  who  get  light- 
headed and  red-faced,  and  are  generally  uncomfort- 
able on  taking  the  smallest  quantity.  These  persons 
have,  I  believe,  less  resisting  power  to  the  disease 
than  those  who  can  take  alcoholics  with  comfort  and 
benefit. 

There  are  numerous  drugs  that,  taken  internally, 
do  various  degrees  of  good ;  they  aid  the  functions 
of  the  body,  and  so  the  powers  of  life,  and  they  are 
mainly  tonics.  But  some  are  corrective  of  faults  of 
secretion,  of  digestion,  and  of  depuration ;  some  are 


General  Principles  of  Treatment  189 

really  foods.  Average  the  cases,  and  it  is  a  truth 
that  in  the  past  too  much  medicine  has  been  given 
to  patients  with  tuljerculosis.  The  doses  have  often 
been  too  large,  and  the  drugs  have  been  given  at 
random  and  without  due  consideration  of  symptoms. 
Great  harm  has  resulted  from  the  excess  of  the 
drugs,  but  far  greater  harm  has  come  from  the 
fact  that  reliance  upon  them  has  obscured  the  potent 
resources  of  hygiene  that  must  always  be  the  main- 
stay in  the  treatment  of  this  disease. 

There  are  measures  acting  locally  on  the  diseased 
resfion  that  are  in  certain  cases  useful.  One  of  these 
is  immobilization  of  the  lung  by  inflation  of  the 
pleural  cavity  with  nitrogen  or  air,  according  to  the 
method  of  Murphy.  This  is  applicable  in  incipient 
one-sided  cases.  Another  is  the  use  of  adhesive 
straps  or  other  apparatus  for  the  same  purpose,  and 
applicable  to  such  cases  in  all  stages  of  the  disease. 
Another  method  is  partial  immobilization  of  the  dis- 
eased lung  by  muscular  control  on  the  part  of  the 
patient  himself.  The  lymph  treatments  are  of  some 
value,  but  only  a  little.  Like  the  use  of  drugs, 
these  measures  are  only  secondary. 

The  climate  treatment  is,  when  properly  used,  the 
best  of  all  the  measures  of  l)enefit ;  but  it  should 
never  be  prescriloed  unless  one  is  sure  that  it  can 
be  taken  in  the  right  way  and  be  attended  1)y  all  the 
aids  that  are  otherwise  available.     Many  times  it  is 


190  Tuberculosis 

worse  than  useless.  The  patient  in  any  climate  must 
be  properly  fed,  housed,  clothed,  and  warmed.  It 
is  just  as  important  that  he  should  have  contentment 
and  mental  peace.  I  would  rather  have  a  patient 
kept  in  the  outskirts  of  an  Eastern  city  (or  even  in 
the  heart  of  the  city),  under  good  hygienic  manage- 
ment, sleeping  in  tlie  best  air  obtainable  winter  and 
summer,  and  with  his  friends  and  comforts  about 
him,  than  to  send  him  to  some  better  climate  to 
shift  for  himself  and  be  lonesome  and  homesick.  If 
a  patient  can  have  all  the  conditions  for  happiness 
in  the  new  country,  then  the  right  change  of  climate 
is  a  thing  of  paramount  consequence;  but  to  send 
him  away  to  a  strange  region  to  shift  for  himself, 
and  perhaps  to  do  a  hundred  foolish  things,  is  worse 
than  useless.  He  may  be  instructed  in  detail  how 
to  take  care  of  himself,  and  he  may  strive  to  follow 
the  directions  implicitly;  but  even  if  he  does  so 
for  thirty  days,  he  is  almost  sure  on  the  thirty-first 
to  do  something  that  will  pull  down  all  the  good 
he  has  done  himself.  Explicit  directions  of  caution 
can  be  observed  to  the  letter  in  a  sanatorium,  and 
if  the  patient  is  subject  to  daily  watchfulness  or  is 
under  the  care  of  a  competent  nurse;  but  almost 
never  when  he  is  left  to  care  for  himself,  and  sub- 
ject to  all  the  conflicting  and  manifold  advice  of 
officious  neighbors. 

It  is  never  safe  to  regard  a  case  of  tuberculosis 


General  Principles  of  Treatment  191 

as  permanently  cured  simply  because  the  symptoms 
have  disappeared.  A  long  time  must  elapse  before 
healed  ulcers  and  closed-up  cavities  can  be  trusted  as 
being  beyond  the  danger  of  easily  breaking  open 
again.  Scar-tissue  must  become  hard  and  quiescent, 
and  a  year  at  least  is  required  for  this  to  occur  — 
and  that  after  all  evidence  of  progressive  disease 
in  the  tuberculous  focus  is  gone.  Nor  is  it  always 
safe  to  rely  on  the  appearance  of  recovery  from  this 
disease  in  the  lungs,  for  active  disease  or  pus  drain 
from  some  other  part  of  the  body  may  cause  a  tem- 
porary abatement  of  the  lung  symptoms  without  the 
slightest  progress  toward  actual  recovery  of  the 
lung.  Cough  and  expectoration  may  subside  and 
rales  disappear  by  the  influence  of  a  diarrhea  or 
a  suppurating  sinus  in  some  other  part  of  the  body, 
or  a  chronic  non-tuberculous  inflammation  in  a  dis- 
tant organ.  Even  the  condition  of  pregnancy  may 
cause  a  nearly  complete  cessation  of  symptoms  until 
parturition  is  over.  Then  the  disease  generally 
flares  up  and  makes  rapid  progress,  usually  to  a  fatal 
termination. 

These  general  principles  will  be  elaborated  and 
enlarged  upon  in  the  chapters  to  follow. 


CHAPTER    XII 
TREATMENT,  HYGIENIC 

The  hygienic  treatment  of  tuberculosis  is  the 
most  important  of  all.  This  means  the  putting  of 
the  patient  under  such  health  conditions  as  to  pre- 
serve and  conserve  to  the  utmost  his  forces  of  life 
and  his  resisting  power  to  the  disease.  In  carrying 
this  out  it  is  important  that  we  should  give  definite 
and  detailed  rules  as  to  what  the  patient  is  to  do, 
how  he  is  to  care  for  himself,  the  food  and  drink 
he  is  to  take  and  the  times  for  taking,  the  hours  to 
be  spent  in  bed,  the  hours  out  of  doors,  and  the 
things  to  do  and  to  omit,  and  all  matters  of  ventila- 
tion, clothing,  excretions,  and  the  care  of  sputum. 
Left  to  himself  he  will  not  follow  good  hygienic 
lines  much,  and  relying  on  verbal  directions  he  may 
forget ;  hence  written  and  minute  directions  are  often 
needed.  They  may  now  and  then  save  a  patient's 
life. 

At  successive  visits  it  is  vastly  more  important 
that  we  should  inquire  if  the  patient  has  carried  out 
his  hygienic  rules  than  if  he  has  taken  his  medicine. 
When  variations  in  the  symptoms  occur  that  are 
unpleasant  or  ominous,  we  can  often  help  him  better 
by  changing  some  detail  of  his  management  than 

192 


Treatment,  Hygienic  193 

by  changing-  his  drug  treatment.  Furthermore,  if 
we  lay  special  stress  on  the  importance  of  these 
rules,  the  patient  will  probably  follow  them;  other- 
wise he  is  likely  to  forget  and  to  become  careless, 
and  do  or  omit  things  that  may  put  him  back  a 
month  in  his  recovery,  or  directly  hasten  his  death. 
In  sanatoria  great  account  is  taken  of  such  details, 
and  patients  come  to  think  of  them  as  more  vital 
than  anything  else  —  more  even  than  their  own 
physiologic  forces.  Wc  can  as  truly  impress  these 
ideas  on  patients  living  in  their  own  homes  if  we  are 
in  earnest  and  insistent,  and  if  we  are  patient  and 
persistent. 

In  carrying  out  this  treatment,  tranquillity  on  the 
part  of  the  patient  and  a  great  deal  of  rest  are 
among  the  most  important  measures.  A  patient 
with  fever  must  be  kept  horizontal  for  at  least  three- 
fourths  of  each  twenty-four  hours.  It  is  often  best 
to  keep  him  in  bed  for  some  weeks  continuously; 
and  he  must  take  his  vertical  life  in  two  to  four 
periods  each  day,  so  that  he  is  never  up  for  long  at 
a  time.  Exercise,  even  the  little  involved  in  the 
erect  posture  for  an  hour  at  a  time,  increases  the 
temperature  of  a  fever  patient.  Given  infection 
enough  to  produce  even  slight  fever,  and  a  small 
amount  of  exercise  is  capable  of  increasing  it. 

The  patient  must  be  guarded  from  distress  of 
mind  as  well  as  body.  If  things  worry  him,  it  is 
13 


T94  Tuberculosis 

just  as  bad  as  if  he  exercised  physically;  it  will  send 
his  temi)erature  up.  To  give  him  the  best  hope  he 
must  also  be  free  from  nostalgia,  for  that  is  as  bad 
as  exercise.  He  must  not  be  worried,  but  cheerful ; 
he  must  l)e  a  philosopher  about  his  own  case,  and 
take  enforced  idleness  gracefully;  and  this  last  is 
probably  the  hardest  lesson  that  he  will  have  to 
learn. 

For  a  tuberculous  patient  with  no  fever,  a  mod- 
erate amount  of  exercise  is  proper;  but  never  for 
the  purpose  of  developing  muscle,  as  that  term  is 
usually  understood ;  never  because  it  is  a  duty ;  solely 
because  he  feels  like  it.  You  get  uj)  in  the  morning 
and  stretch  3'our  muscles  because  it  makes  you  feel 
good  to  do  so;  you  take  a  walk  because  every  step 
is  a  joy.  Your  non-febrile  tuberculous  patient  may 
exercise  on  that  l)asis  with  propriety,  but  should 
never  carry  it  to  the  extent  of  the  slightest  fatigue 
that  is  not  promptly  recovered  from  by  brief  rest. 

Many  a  time  the  patient  will  not  be  aljle  to  sleep ; 
he  will  fret  and  fume  because  he  cannot,  which  al- 
ways increases  the  wakefulness.  For  this  symptom 
drugs  are  to  be  avoided  if  possible,  unless  the  sleep 
is  broken  by  dry  and  unproducti\'e  cough.  A  potent 
remedy  for  nervous  insomnia  is  for  the  patient  to  re- 
solve that  he  does  not  wish  to  sleep  and  will  stay 
awake,  and  in  nine  cases  out  of  ten  he  will  drop  into 
slumber  in  a  few  minutes.   To  sleep  well  one  must  be 


Treatment,  Hygienic  195 

tranquil  and  untroubled;  and  if  he  sincerely  resolves 
that  he  prefers  not  to  sleep,  but  to  lie  awake  and 
perhaps  read  an  unexciting  book,  that  mental  atti- 
tude makes  him  tranquil  and  invites  drowsiness.  A 
hot-water  bottle  or  a  hot  foot-bath  for  cold  feet  will 
often  induce  sleep ;  as  will  an  enema  for  a  loaded 
colon,  or  a  drink  of  sodium  bicarbonate  solution  for 
a  sour  stomach,  or  of  warm  milk  for  an  empty  one. 

The  thing  that  a  physician  will  find  most  difficult 
to  bring  about  with  such  patients  is  the  outdoor  life. 
That  is  nearly  if  not  quite  as  important  as  the  rest 
of  body  and  mind,  and  it  is  the  chief  factor  of 
benefit  in  nearly  all  the  climatic  influences  that  come 
to  these  patients  —  the  outdoor  life,  the  breathing  of 
fresh,  pure  air,  and  the  getting  of  some  sunshine. 
The  sunshine  is  extremely  valuable,  but  less  so  than 
the  fresh  air. 

There  may  be  elements  in  the  outdoor  air  that  are 
valuable  besides  the  due  amount  of  oxygen  and  the 
freedom  from  contamination,  but  we  assume  that 
these  are  its  chief  advantages.  We  had  thought  for 
a  century  that  we  knew  all  that  the  atmosphere  was 
composed  of,  and  all  the  advantages  of  a  pure  air 
and  all  the  disadvantages  of  an  impure  one.  It 
was  left  to  the  last  decade  to  discover  in  the  air  the 
new  substance  argon,  of  whose  influence  on  animal 
I)hysiology  we  are  completely  ignorant.  Other  ele- 
ments may  still  be  discovered  that  possibly  will  fur- 


196  Tuberculosis 

ther  explain  the  great  influence  of  slight  changes 
of  the  atmosphere  on  the  human  Ixxly.  Patients 
should  religiously  kee^)  away  from  indoor  crowds, 
whether  in  theater,  hall,  or  church;  for  there  they 
always  breathe  the   worst   possible  atmosphere. 

There  is  no  doubt  of  the  great  value  of  outdoor 
life  to  these  patients,  and  it  must  l)e  mostly  due  to 
the  better  air  they  breathe.  It  has  been  found  prac- 
tically impossible  to  ensure  in  a  house  or  a  hospital 
ward,  wdth  any  attainable  provision,  a  constant  at- 
mosphere that  does  not  contain  at  least  twice  as 
much  of  those  contaminations  harmful  to  man  as 
are  found  in  the  outer  air.  This  is  a  sufficient  ex- 
planation of  the  great  benefit  that  patients  experience 
from  living  out  of  doors. 

It  requires  a  great  deal  of  preaching  and  persist- 
ency on  the  part  of  the  doctor  to  keep  some  of  the 
patients  out  of  doors.  They  will  hesitate,  fear  they 
will  take  cold,  declare  it  will  kill  them ;  and  gen- 
erally fail  to  appreciate  the  vast  importance  of  this 
measure. 

Even  when  one  has  consented  to  try  to  do  it,  the 
art  of  staying  out  of  doors  is  one  that  has  to  be 
learned.  Especially  is  this  true  when  the  weather 
is  cool  or  cold.  A  man  told  to  be  out  of  doors 
say  for  ten  hours  a  day  \\\\\  sit  on  a  porch  if  it  is 
warm  and  agreeable ;  but  if  it  is  cool  he  wdll  think 
he  must  walk  constantly  or  ride  horseback  to  avoid 


Treatment,  Hygienic  197 

feeling  chilly.  The  horseback  riding  is  beyond 
most  of  the  patients,  and  even  that  exercise,  indulged 
in  for  hours,  is  tiring  to  the  sick,  so  that  most  of 
them,  left  to  themselves,  will  walk  and  walk  to 
keep  warm.  They  thus  get  themselves  tired  and 
worn  out,  and  often  bring  on  fever,  to  their  harm. 
Yet  these  very  people  find  it  natural  and  comfortable 
to  ride  in  an  open  carriage  on  the  same  cool  days 
that  they  would  fear  to  sit  on  a  porch. 

It  is  one  of  the  curiosities  of  the  psychology  of 
invalidism  that  it  never  occurs  to  the  patient,  unless 
he  is  told  of  it,  that  he  can  wrap  himself  in  warm, 
thick  clothes,  put  on  mittens  and  overshoes,  and 
put  a  heavy  lap-robe  about  his  legs  and  feet,  ex- 
actly as  he  would  if  going  driving,  and  sit  or  lie 
on  a  porch  or  on  the  ground  for  hours,  and  get  all 
the  advantages  of  a  carriage  ride  safely  and  without 
its  expense.  The  physician  must  go  into  all  these 
details  with  patients,  and  many  times  over  if  nec- 
essary, to  help  them  to  the  benefits  of  outdoor  life. 
The  delicate  patients  should  lie  on  a  cot  or  a  reclin- 
ing chair,  as  their  condition  requires. 

Some  of  the  patients  are  so  literal  that  they  will 
try  to  carry  out  their  directions  regardless  of  all 
variations  in  conditions,  and  often  make  themselves 
very  uncomfortable  in  consequence.  Told  that  sun- 
shine is  good  for  them,  tliey  will  take  it  in  its  in- 
tensity every  hour  of  the  day.     The  patient  should 


198  Tuberculosis 

lie  or  sit  in  shade  or  sun  as  his  comfort  requires. 
He  must,  if  possil)le.  be  comfortable  at  all  times. 
I  have  often  seen  a  consumpti\e  torture  himself 
for  hours  jjy  sitting  in  the  hot  sunshine,  l)ecause  he 
sujjposed  it  was  his  duty,  and  had  n(>t  the  acumen 
to  know  that  all  prescriptions  for  the  sick  are  to 
be  taken  with  some  measure  of  common  sense. 

A  tubercul(jus  patient  ought  to  sleep  with  a  slight 
zephyr  of  air  moving  over  his  face.  The  physician 
may  be  accused  of  recklessness  and  cruelty  in  advis- 
ing such  a  thing,  but  the  fact  is  that  one  can  sleep 
out  of  doors  with  the  wind  blowing  over  his  face 
at  any  time  witliout  taking  cold,  provided  his  body 
and  head  are  warm.  If  these  proper  precautions 
are  taken,  you  may  defy  any  patient  to  take  cold. 
Most  patients  can  be  educated  to  sleep  in  the  open, 
to  the  point  where  they  will  feel  lost  without  a 
little  movement  of  air  over  their  faces.  Soldiers 
sleep  under  tents  or  trees,  or  out  under  the  sky 
with  their  blankets  wrapped  about  them,  and  rarely 
have  colds.  Let  them  go  home  and  sleep  in  rooms 
with  closed  windows,  and  they  will  soon  begin  to 
sneeze  and  cough. 

If  a  patient  sleeps  in  a  ^■ery  cold  place  or  in  the 
wind,  he  should  wear  a  night-cap.  The  best  kind 
is  a  knitted  jersey  affair  that  may  be  easily  drawn 
over  the  head.  If  it  is  \-ery  cold,  he  should  sleep 
between  woolen  blankets.     lie  must  be  so  wrapped 


Treatment,  Hygienic  199 

up  and  protected  that  he  can  sleep  with  the  tem- 
perature at  zero  without  discomfort.  After  he  be- 
comes adjusted  to  it  he  will  thank  you  for  the  de- 
lights that  you  have  led  him  to.  Occasionally,  if 
an  afebrile  patient  feels  cold,  he  will  have  what  he 
terms  rheumatic  pains;  they  are  generally  merely 
neuralgic  pains,  mostly  in  the  muscles,  and  will 
rarely  occur  if  the  patient  is  constantly  warm,  unless 
his  digestion  is  out  of  order  in  some  way. 

The  patient  sleeping  in  a  cold  room  should,  if 
possible,  have  a  warm  place  in  which  to  dress,  al- 
though this  is  not  indispensable,  provided  he  has 
good  vigor  and  is  able  to  dress  rapidly.  For  the 
weakly  ones  with  poor  blood-making  powers,  who 
tire  and  breathe  rapidly  on  exertion,  we  ought  to 
invent  clothing  that  requires  little  change  on  rising 
from  bed.  For  this  class  of  patients  of  both  sexes 
the  ordinary  day  clothing  involves  a  wickedly  use- 
less waste  of  time  and  strength  and  heat  in  being  put 
on  and  taken  off.  /Vny  nurse  or  patient  can  devise  a 
set  of  garments  that  will  considerably  minify  this 
waste,  provided  the  patient  will  pocket  his  pride  and 
forego  his  ambition  to  appear  dressed  (and  in  bed 
even)  like  well  people.  The  day  garments  should  be 
fewer,  simpler,  and  looser  than  is  fashionable;  they 
should  more  resemble  the  bed  garments ;  and  some 
of  them  may  be  identical  with  the  latter.  There  is 
no  law  against  wearing  thick  pajamas  both  in  and 


200  Tuberculosis 

out  of  bed ;  and  a  single  long,  thick  gown  will  cover 
and  protect  the  body  both  in  and  out  of  bed.  The 
common  multiplicity  of  garments  is,  like  appetite, 
something  provided  for  the  well ;  for  the  sick  they 
may  be  a  grievous  and  a  useless  burden,  as  they  al- 
ways are  in  the  face  of  cold  and  fatigue. 

Clothing  should  be  simple  and  loose,  should,  if 
possible,  cover  the  body  equably,  and  should  give 
a  sense  of  warmth,  not  one  of  heat.  Chest-pro- 
tectors and  alxlominal  bands  are  not  to  be  advised 
unless  the  patients  like  them.  No  tight  clothing 
should  be  permitted ;  corsets  are  usually  a  nuisance 
for  a  tuberculous  woman ;  and  tight  collars  and 
shoes  and  heavy  head-gear  should  be  tabooed  per- 
manently. There  is  a  vast  amount  of  useless  cough 
at  night,  by  some  patients,  due  to  the  fact  that  the 
clothing  over  the  neck,  shoulders,  chest,  and  arms 
is  thinner  than  that  worn  by  day.  This  should 
never  be  permitted ;  more  rather  than  less  should 
be  worn  at  night. 

The  quantity  of  clothing  is  a  great  bone  of  con- 
tention with  many  of  the  younger  women  patients 
and  a  few  of  tlie  younger  men.  They  often  de- 
clare that  they  are  wariu  and  feel  warm,  even  in 
cold  weather,  with  garments  so  few  and  so  thin  as 
to  terrify  their  mothers  and  sometimes  their  doctors. 
They  make  this  declaration,  too,  when  their  hands 
and  noses  are  blue  with  cold ;   yet  they  protest  their 


Treatment,  Hvsfienic  201 


fc) 


candor,  and  that  they  have  no  sentiment  against 
more  clothes. 

In  connection  with  such  cases,  it  is  well  to  remem- 
ber a  few  truths  of  human  nature  as  well  as  of 
human  pathology.  One  is  that  we  rarely  take  cold 
solely  from  lack  of  clothes,  but  often  from  debility, 
fatigue,  indigestion,  and  lack  of  excretion  from  the 
body.  These  thinly-clad  youths  do  not  often  appear 
to  suffer  injury  solely  from  their  cold  extremities 
and  noses,  lout  they  do  from  other  conditions  named. 
Then,  it  has  a  harmful  influence  on  the  spirits  of 
such  a  one  to  nag  her  perpetually  about  her  clothes ; 
it  conduces  to  spiritual  rebellion  and  consequent 
failure  of  digestion  and  sleep.  She  might,  perhaps, 
be  better  off  developing  the  qualities  of  the  aborig- 
ines as  to  her  clothes,  than  have  dyspepsia  and 
insomnia.  On  the  other  hand,  it  is  perhaps  true 
that  such  lack  of  clothing  may  bring  on  or  hasten 
Bright's  disease  in  a  tuberculous  patient.  It  is 
better  to  have  the  skin  warm  and  near  the  sweating 
point,  for  the  sake  of  its  function  as  an  excreting 
organ. 

On  the  psychologic  side  it  is  true  that  vanity 
and  foolishness  as  to  appearances  control  many  of 
these  simple  people  without  their  consciousness  of 
the  fact.  They  fil)  about  tlicir  sensations  as  easily 
and  as  blindly  as  a  girl  denies  that  her  corset  is 
tight,   or   a   boy   that   his    shoes   bind   or    that   his 


202  Tuberculosis 

collar  is  uncomfortable.  Besides  this,  it  seems  to 
be  a  normal  mental  trait  of  many  sensitive  unathletic 
women  to  hate  physical  sensations  of  warmth  and 
of  perspiration.  It  is  a  quality  of  the  neurotic, 
is  temperamental,  and  can  hardly  be  argued  out  of 
a  woman.  But  the  excessive  touchiness  to  a  sensa- 
tion of  heat  produced  l)y  clothes  is  to  a  large  degree 
one  of  unnecessary  sentiment ;  even  neurotics  get 
over  it  easily  if  they  find  the  clothing  is  inevitable. 

I  suppose  it  is  an  uncontrovertible  truth  that  any 
severe  strain  on  the  system  to  maintain  its  body 
heat  in  cold  weather  may  lessen  its  power  to  resist 
tuberculosis.  So  it  is  best  to  insist  on  a  proper 
amount  of  clothing,  even  if  it  does  cause  some 
little  mental  anguish. 

It  is  not  important  that  the  skin  clothing  should 
always  be  of  wool,  contrary  to  the  general  impres- 
sion, although  this  is  a  most  proper  fabric.  Silk, 
cotton,  and  linen  will  do  well  enough,  if  they  are 
woven  loosely,  so  as  to  contain  many  air  spaces. 

The  question  of  baths  is  a  worrying  one  to  some 
consumptives.  Many  good  people  seem  to  feel  that 
they  are  guilty  of  a  mortal  sin  if  they  do  not  wash 
their  bodies  all  over  e\'ery  day,  and  that  somehow 
if  they  are  always  clean  they  have  a  right  to  expect 
to  be  well ;  also  that  the  something  called  the  stop- 
ping of  "  the  pores  of  the  skin  "  is  fraught  with 
the  most  dire  consef|uences,  which  baths  prevent. 


Treatment,  Hygienic  203 

Unfortunately,  no  such  theory  will  stand ;  for 
many  very  filthy  people  seem  to  get  on  quite  as 
well  as  those  who  bathe  e\'ery  day.  And  no  stop- 
ping of  the  pores  of  the  skin  by  any  ordinary  un- 
cleanliness  of  the  surface  seems  able  to  interfere 
with  the  free  flow  of  perspiration  whene\'er  the 
conditions  are  otherwise  favorable  for  that  function. 

Yet  it  is  probably  true  that  a  daily  bath  is  benefi- 
cial to  a  moderate  degree,  provided  it  does  not  tire 
the  patient  unduly  or  chill  his  body  too  much.  It 
carries  away  some  of  the  superficial  epithelium,  and 
in  the  taking  of  the  bath  some  manipulation  of  the 
surface  tissues  is  produced  which  has  a  good  effect. 
But  the  bath  never  can  be  reckoned  as  of  much 
value  when  compared  with  proper  food,  rest  of  the 
body,  and  a  supply  of  pure  air  and  other  physical 
comforts.  Well-selected  tonic  medicine  is  worth  in- 
comparably more  than  baths ;  and  when  the  bath  is 
taken  at  the  expense  of  needed  physical  strength,  as 
well  as  when  it  leads  to  shivering  of  the  body  from 
cold  —  often  lasting  for  an  hour  —  it  is  worse  than 
useless  and  ought  not  to  be  resorted  to  often. 

It  is  rational  to  suspect  that,  by  reflex  action,  stim- 
ulation of  the  skin  to  just  the  necessary  degree  by 
baths  containing  some  stimulating  substance,  such 
as  mustard,  capsicum,  or  carbon  dioxid,  might  do 
good  if  it  were  to  be  used  regularly  and  for  a  long 
time.     But  this  cannot  be  asserted   until   lone'  and 


204  Tuberculosis 

careful  trial  has  shown  it  to  be  true.  Unfortu- 
nately, most  of  the  experimentation  with  baths  has 
been  clone  by  specialists  in  hydrotherapy — a  circum- 
stance not  conducive  to  unbiased  reports. 

Rubbing  of  the  skin  thoroughly  with  a  coarse,  dry 
towel  is  a  measure  nearly  or  quite  as  conducive  to 
good  hygiene  of  the  surface  as  any  bath,  while  it  is 
safer  for  most  consumptives. 

One  of  the  very  important  things  is  the  diet. 
The  patient,  if  at  all  del)ilitated,  must  eat  oftener 
than  usual,  preferably  six  times  a  day.  One  need 
not  dignify  all  these  eatings  as  formal  meals,  and 
the  patient  must  be  disabused  of  the  notion  that 
he  is  expected  to  eat  a  great  deal  each  time.  He 
may  not  be  asked  to  eat  a  total  of  more  than  he 
has  taken  in  his  previous  three  meals,  but  it  must 
be  distributed  over  six  doses.  And  he  must  l)e 
forbidden  to  take  at  any  time  a  large  meal,  as  that 
might  provoke  an  indigestion  from  which  he  could 
not  recover  in  weeks.  He  should  take  an  early 
breakfast,  eat  again  in  the  middle  of  the  forenoon, 
at  noon,  mid-afternoon,  at  nightfall,  and  before 
going  to  bed. 

Many  will  declare  that  they  have  no  appetite; 
that  they  cannot  swallow  food  so  often;  that  they 
will  surely  Ijecomc  bilious,  or  that  tliey  will  \-omit. 
But  such  fears  are  mostly  groundless.  If  the  pa- 
tients trv  to  eat  six  times  a  dav.  thev  usuallv  succeed. 


Treatment,  Hygienic  205 

They  soon  find  that  they  can  do  it  with  as  much 
ease  as  they  formerly  ate  three  times,  and  that  they 
take  considerably  more  in  the  aggregate.  Most  of 
them  even  come  to  like  this  way  of  taking  their 
food;  it  helps  them  to  learn  that  the  thing  called 
appetite,  which  is  nature's  device  for  well  people, 
is  not  necessary  in  order  to  take  a  small  amount  of 
food,  and  that  they  can  even  ignore  it. 

Most  squeamish  patients  eating  three  times  a  day 
have  a  poorly  selected  diet.  They  follow  their 
whims,  and  so  take  many  articles  of  low  food  value, 
like  fruits,  salads,  green  vegetables,  and  ices.  At 
least  they  often  do  this  for  two  meals  each  day, 
while  for  the  other  they  eat  inordinately  of  hearty 
foods,  and  in  conse(|uence  often  get  indigestion. 
Eating  from  four  to  six  times  a  day  removes  the 
temptation  to  over-eat  at  any  meal,  and  abolishes  the 
pathetic  struggle  to  find  something  to  please  a  mor- 
bid appetite  to  which  the  patient  instinctively  thinks 
he  must  cater.  He  now  eats  as  a  matter  of  routine, 
and  even  forgets  whether  he  has  an  a])pctite ;  that 
emotion  becomes  a  negligible  element  in  his  daily 
life. 

The  articles  of  food  are  important  and  should 
be  insisted  on.  Four  common  articles  are  about 
all  that  is  necessary  —  bread,  meat,  eggs,  and  milk 
and  its  products.  Breadstuffs  or  starches  should 
consist  of  stale  bread  or  crackers,  toasted  if  pre- 


2o6  Tuberculosis 

ferred,  and,  as  a  rule,  eaten  with  l)Utter.  There  is 
no  need  of  rice,  potatoes,  or  mushes  of  any  de- 
scription, although  there  is  no  necessary  objection 
to  them  if  they  can  be  well  insalivated.  This  latter 
is  a  difficult  thing  to  do  with  any  mush,  and  the 
bread  should  be  eaten  dr}'  and  stale,  so  as  to  en- 
courage a  free  How  of  saliva.  Almost  any  tender 
meat  is  proper.  The  eggs  should  be  soft-cooked  or 
raw.  The  milk  may  be  raw  or  pasteurized  (r6o° 
F.),  never  sterilized  (212°  F.),  and  may  be  com- 
bined in  numerous  mixtures.  These  four  articles 
are  all  that  the  human  body  needs,  provided  some 
of  the  milk  is  taken  uncooked.  If  the  milk  must 
all  be  cooked,  then  it  is  better  if  there  is  a  little 
fruit  or  some  vegetables  taken  each  day  to  ward 
off  any  tendency  to  scorbutus. 

Patients  will  frequently  object  to  what  they  are 
likely  to  call  such  a  restricted  diet;  but  it  is  not 
restricted.  A  vast  dietary  may  be  made  out  of  these 
four  articles.  A  dozen  kinds  of  meat  are  possible. 
Rare  or  raw  meat  is  the  best,  and  some  recent  ob- 
servers have  offered  evidence  that  raw  meat  is  inim- 
ical to  the  growth  of  tubercle  bacilli  in  the  human 
body.  Whether  it  shall  be  shown  that  this  is  always 
true,  or  whether  the  benefit  is  because  the  raw 
meat  is  more  easily  digested,  there  is  certainly  little 
or  no  objection  to  taking  raw  beef.  It  should  be 
chopped  fine,  and  it  may  be  flavored  in  any  way 


Treatment,  Hygienic  207 

to  suit  the  taste  —  with  salt  and  pepper,  or  mixed 
with  nutmeg,  allspice,  cinnamon,  lemon-juice,  or 
anchovy,  and  spread  thin  between  slices  of  dry 
bread  in  sandwiches.  Patients  come  to  enjoy  it  in 
this  way.  The  eggs  may  be  cooked  rare  in  a  variety 
of  forms,  the  curdled  egg^  being  the  best,  or  they 
may  be  taken  raw.  One  of  the  best  forms  is  an 
egg-nog  which  combines  milk  and  sugar  with  a 
moderate  dose  of  some  alcoholic  stimulant.  If  this 
is  properly  prepared  and  flavored  to  the  taste  of 
the  patient,  he  will  usually  relish  it,  especially  if  it 
is  cold  and  taken  through  a  straw  or  a  glass  tube. 
The  best  flavor  is  perhaps  produced  by  one  part  of 
rum  and  four  parts  of  whiskey,  a  tablespoon ful  be- 
ing used  to  a  glass  of  the  mixture.  ]\Iilk  may  be 
prepared  in  many  forms,  and  stale  bread  may  be 
made  to  appear  in  many  different  ways  for  the  sick. 
You  must  resort  to  various  devices  to  make  your 
patients  eat.  Many  will  declare  that  they  cannot 
take  milk  —  that  it  causes  l)iliousness  and  leaves 
a  disagreeable  taste  in  the  mouth.  But  the  latter 
can  be  rinsed  out  of  the  mouth  with  a  little  water, 
perhaps  flavored  with  something.  Most  patients 
can  digest  milk  if  it  is  taken  in  small  drafts  — 
that  is,  a  teaspoonful  at  a  time. 

lAn  egg  is  "curdled"  by  being  dropped  (unbroken)  into 
a  small  kettle  of  boiling  water,  wbicb  is  at  that  instant  taken 
off  the  stove  and  set  on  the  hearth.  In  five  to  eight  minutes 
it  is   sufficiently   cooked. 


2o8  Tuberculosis 

A  bili(Uis  suljject  slioukl  never  drink  niiik  in 
quantity,  as  it  may  form  a  mass  of  curd  in  the  stom- 
ach ;  he  should  take  it  broken  up  in  the  way  de- 
scribed, or,  better,  with  some  breadstuff  eaten  with 
it  or  between  its  mouthfuls,  so  as  to  dihite  it.  A 
Httle  cooked  starch  —  a  small  teaspoonful  to  a  pint, 
as  advised  by  Prof.  \V.  S.  Haines  —  or  a  cracker 
crushed  and  mixed  with  a  pint  of  milk  will  pre\'ent 
its  forming  into  hard  curds  in  the  stomach.  The 
same  purpose  may  be  helped  by  a  little  sodium  bi- 
carbonate taken  just  before  eating-.  The  taste  of 
milk  may  Ije  changed  by  the  addition  of  charged 
seltzer  water;  and  if  there  is  any  danger  that  it 
is  not  in  prime  condition,  it  should  be  pasteurized 
by  being  heated  to  i6o°  F.,  but  it  should  never  be 
boiled.  Slightly  sour  or  clabbered  milk  is  some- 
times relished  and  is  altogether  wholesome ;  but- 
termilk is  a  delightful  thing  to  many  invalids;  and 
koumyss  is  another  eligible  form  of  milk. 

With  a  majority  of  tuberculous  patients  specific 
directions  must  be  given  about  the  taking  of  food 
as  well  as  about  the  food  itself.  Then  the  physi- 
cian must  not  stop  with  prescribing  the  right  diet 
and  the  right  kind  of  eating,  but  must  aid  digestion, 
both  of  the  proteids  and  the  starch  foods.  For  the 
former  nothing  is  so  good  as  pepsin  with  hydro- 
chloric acid  taken  soon  after  meals ;  but  for  certain 
patients   papoid   and   pineapple-juice   are   decidedly 


Treatment,  Hygienic  209 

beneficial.      For  the  starch    foods  there  is  perhaps 
nothing  better  than    taka-diastase  and   diazyme. 

For  patients  with  too  much  acid  in  the  stomach, 
as  shown  by  eructations  of  acid  fluid  or  otherwise, 
an  excehent  thing  is  a  dose  of  20  to  60  grains  of 
sodium  bicarbonate  dissohed  in  half  a  glass  of  hot 
water,  and  taken  preferably  half  an  hour  before  a 
meal.  It  is  proper,  however,  any  time  after  eating, 
Avhen  the  proof  of  a  sour  stomach  is  present.  Flot 
water  helps  many  of  these  patients  with  their  di- 
gestive troubles,  a  glassful  being  taken  in  sips 
shortly  before  a  meal.  Like  the  soda,  it  seems  to 
aid  the  stomach  in  freeing  itself  from  the  debris 
of  a  previous  meal,  probably  by  coaxing  the  pylorus 
to  relax. 

Lavage  should  be  tried  in  all  cases  of  persistent 
gastric  indigestion  in  tuberculosis.  IMany  of  these 
cases  have  an  excess  of  acid,  probably  pyloric  spasm, 
and  consequent  gastric  dilatation,  which  this  meas- 
use  is  potent  to  correct.  I  ha\e  known  cases  to 
recover  under  the  use  of  lavage,  that  seemed  to  be 
doomed  to  die  until  it  was  resorted  to.  The  stomach 
should  be  washed  out  e\-ery  day  if  it  seems  best, 
even  oftener  than  once  if  recjuired,  although  once  is 
usually  sufficient.  Sometimes  great  relief  is  found 
in  a  lavage  every  second  or  third  day.  The  best 
time  for  most  cases  is  perhaps  two  or  three  hours 
after  the  last  meal  of  the  day. 
14 


2IO  Tuberculosis 

By  the  lavage  the  particles  of  undigested  food 
and  more  or  less  mucus  are  evacuated,  the  stomach 
is  collapsed,  and  the  patient  generally  sleeps  better 
for  it.  He  gets  up  hungry,  to  eat  well  the  next  day, 
taking  six  meals  and  digesting  them.  Many  of  the 
cases  grow  better  daily  after  the  lavage  is  begun. 
But,  of  course,  in  some  instances  no  benefit  results 
even  after  several  trials;  then  it  should  be  promptly 
abandoned  as  a  treatqient,  for  it  is  the  rule  that  any 
benefits  from  this  measure  are  experienced  rather 
promptly. 

Many  consumptives  have  trouble  with  their  bow- 
els—  sometimes  very  annoying  ones  (not  due  to 
tuberculosis  of  the  intestines),  that  retard  or  prevent 
their  recovery.  It  may  take  the  form  of  pain,  flat- 
ulence, constipation,  or  diarrhea,  or  these  last  two 
conditions  may  alternate  e\ery  few  days.  True 
chronic  intestinal  catarrh  may  exist,  with  all  its 
attendant  conditions.  This  trouble  not  infrequently 
is  due  to  lack  of  drainage  of  the  colon  and  sigmoid, 
hecal  matter  is  retained  in  the  pockets  and  tortuosi- 
ties of  these  parts  until  it  provokes  diarriiea,  after 
which  constipation  returns.  Sometimes  the  patient 
takes  a  dose  of  physic  to  relieve  the  bowel,  and  this 
produces  diarrhea,  to  be  followed  by  worse  consti- 
pation than  before.  This  state  of  things  is,  of 
course,  inimical  to  good  health  and  good  digestion. 
It  too  often  produces  ischiorectal  abscesses  and  re- 


Treatment,  Hygienic  211 

suiting  fistulse,  which  rarely  heal  if  the  vitality  of 
the  body  is  low. 

The  best  remedy  for  the  condition  is  daily  rather 
large  warm  enemas  of  normal  salt  solution  (a 
heaped  teaspoonful  —  130  grains  —  of  common  salt 
to  a  quart  of  water)  to  wash  out  the  descending 
colon  and  sigmoid,  if  not  the  entire  large  intestine. 
It  will  frequently  stop  a  diarrhea,  proving  it  to 
have  been  due  to  some  retention  in  the  large  bowel, 
and  stop  the  nagging  discomfort  of  colicky  pains 
that  so  often  attend  this  disorder.  At  the  same  time 
it  will  often  improve  the  condition  of  the  stomach 
in  respect  to  both  its  sensations  and  its  digesting 
power. 

The  enemas  should  be  used  rather  warmer  than 
the  body  temperature — 100 "^  to  105°  F.  (110° 
does  not  hurt  the  body),  and  can  be  used  without 
danger.  It  is  not  always  possible  to  use  them, 
as  they  occasionally  disagree  with  the  patient  in 
some  way  (most  often  by  an  absurd  attempt  on  his 
part  to  retain  the  Ihiid  for  some  time  against  a  nor- 
mal impulse  to  expel  it)  ;  and  we  daily  encoun- 
ter the  popular  fallacy,  as  senseless  as  it  is  ground- 
less, that  there  is  danger  of  forming  something 
that  may  be  called  "  the  enema-ha1)it,"  and  that  will 
continue  through  life  and  l)e  fraught  with  some 
dire  calamity.  If  enemas  are  a  comfort  to  the 
patient  and  help  his  digestion,  they  should  be  used 


212  Tuberculosis 

regularly;  if  they  are  not,  they  must  be  abandoned, 
but  no  whim  of  the  patient,  nor  his  esthetic  squeam- 
ishness  about  taking  them,  must  stand  as  an  obsta- 
cle for  an  instant.  The  presence  of  tuberculosis 
of  the  intestine  is  no  l)ar  to  the  use  of  enemas,  pro- 
vided they  relieve  discomfort  and  aid  digestion. 

Massage  is  fre(|uently  beneficial  in  tuberculosis. 
It  takes  the  place  of  exercise,  and  may  be  comfort- 
ing to  the  patient.  But  the  skin  and  muscles  are 
often  sensitive  and  tender ;  hence  manipulations 
must  be  gentle  and  brief.  Light  rubbing  of  the 
skin  with  alcohol,  or  with  oil  after  free  washing 
with  soap  or  alkaline  water,  may  comfort  the  ])atient 
and  do  some  slight  good.  There  was  a  time  when 
we  felt  sure  that  oils  rubbed  into  the  skin  Avere  to 
a  large  extent  absorbed  and  so  might  nourish  the 
system ;  Init  the  experimental  work  of  the  labora- 
tories seems  to  have  proved  that  view  to  have  been 
delusive.  We  now  rub  the  skin  with  oil  for  the 
comfort  of  the  patient  or  the  good  of  the  skin  itself, 
and  rely  on  the  digestixe  canal  to  carry  nutriment 
into  the  general  system. 

Light  massage  in  one  form  or  another  may  be 
beneficial  because  it  di\'erts  the  patient's  mind  from 
his  disagreeable  thoughts  and  sensations,  and  takes 
the  place  of  exercise  which  he  is  perhaps  forbidden 
to  have;  and  because  it  is  good  for  the  skin  and  is 
some  help  to  nutrition.     Nor  should  it  be  used  upon 


Treatment,  Hygienic  213 

a  part  of  the  body  that  is  tuberculous.  Therefore 
all  swollen  joints,  glands  and  other  tissues,  whether 
tender  or  not,  should  be  avoided  in  such  manipula- 
tions. Just  the  contrary  is  the  tendency  of  nearly 
all  who  are  engaged  in  giving  massage.  Many  of 
them  seem  possessed  of  two  cardinal  and  most  erro- 
neous notions :  one,  that  they  are  in  duty  bound 
to  rub  out  every  pain  and  force  away  every  swell- 
ing ;  and  the  other,  that  they  are  physicians,  although 
they  protest  the  contrary. 


CHAPTER   XIII 
THE     MANAGEMENT     OF     THE    DISEASED     LUNG 

The  hygiene  of  the  diseased  lung  itself  is  a  sub- 
ject of  great  importance.  The  wise  and  useful 
practice  of  the  profession  in  treating  ah  varieties  of 
tuberculosis,  except  that  of  the  lungs,  has  been  to 
put  the  part  at  rest  so  far  as  possible.  Just  the 
opposite  course  has  oljtained  in  managing  the  lungs. 
The  almost  uniform  practice  has  been,  as  soon  as 
these  organs  become  tuberculous,  to  urge  the  patient 
to  take  repeated  deep  breaths  and  "  expand  the 
lungs."  Various  exercises  have  been  prescribed  to 
this  end.  Little  tuljes  have  been  used  to  breathe 
through,  the  expiration  being  made  under  pressure, 
so  as  to  stretch  the  air-vesicles  as  much  as  possible; 
and  both  patient  and  doctor  have  been  proud  if  the 
measuring  tape  has  shown  an  increase  in  the  cir- 
cumference of  the  chest. 

All  these  methods  are  harmful  and  wrong.  There 
is  no  proof  that  the  lung  is  an  exception  to  the  rule 
that  tuberculous  organs  do  best  when  perfectly  qui- 
escent; and  there  is  nnicli  evidence  to  the  contrary. 
A  diseased  lung  needs  to  be  ])ut  to  rest  so  far  as 
it  can  1)e.  To  this  end  there  should  be  no  deep 
breathing  unless  ,the  affected   lung  can   be  put   to 

214 


The  Management  of  the  Diseased  Lung     215 

rest  and  the  work  of  respiration  be  done  mostly  or 
entirely  by  the  well  one.  Any  obstruction  to  the 
outflow  of  air  is  certainly  harmful,  since  it  does 
violence  to  the  lung-tissue;  and  no  tuberculous 
lung  should  ever  be  allowed  to  expand  and  grow 
larger.  Even  cough  should  be  suppressed  when- 
ever possible,  in  order  to  avoid  the  stretching  and 
injury  to  the  diseased  tissues. 

One  of  the  results  of  violence  to  an  ulcer  on  the 
surface  of  the  body  is  to  increase  the  amount  of 
scar-tissue.  The  smallest  scar  forms  where  clean 
and  sterile  surfaces  are  brought  together  and  kept 
still.  If  you  prod  a  sore  every  day  you  should 
expect  to  see  it  heal  slowly  and  with  a  large  amount 
of  new  connective  tissue  that  will  contract  after- 
ward. The  tuberculous  lung  heals, if  at  all,  with  more 
or  less  new  connective  tissue  (l  c.  scars)  around 
and  in  the  midst  of  the  diseased  area.  That  is  na- 
ture's way  of  cure  and  we  call  it  "  fibrosis."  The 
new  tissue  contracts  after  the  cure,  and  causes  more 
or  less  narrowing  of  the  lung.  The  process  is  pre- 
sumably conservative;  but  if  too  much  fibrosis  oc- 
curs, the  contraction  cripples  the  lung  and  may 
itself  destroy  life.  The  irritation  of  the  disease 
starts  the  deposit  of  new  tissue,  and  the  great  de- 
sideratum is  to  have  as  little  fibrosis  as  possible 
consistent  with  cure;  that  is,  to  have  a  minimum 
of  damage  to  lung-tissue  after  recovery. 


2i6  Tuberculosis 

There  can  Ije  little  doubt  that,  other  things  being 
equal,  the  amount  of  fibrosis  bears  some  proportion 
to  the  measure  of  \-iolence  or  motion  to  which  the 
lung  tissue  has  been  subjected  during  the  disease. 
If  this  is  true,  it  is  our  duty  to  minify  or  abolish 
the  motion  of  the  diseased  lung.  The  only  way  to 
abolish  it  \vh(j]ly  is  to  inflate  the  pleural  cavity  with 
sterile  air  or  nitrogen  gas  after  the  manner  of  Mur- 
phy. This  treatment  is  applicable  to  the  incipient 
cases  of  unilateral  tuberculosis  without  adhesions. 
The  effect  of  it  is  to  collapse  the  lung  and  stop  all 
of  its  motion ;  then  the  pus  that  gets  into  the  bronchi 
by  the  gentle  pressure  of  the  tissues  flows  out  mto 
the  trachea,  to  be  coughed  up  by  blasts  of  air  from 
the  other  lung.  The  diseased  lung  thus  put  to  rest 
often  recovers. 

The  treatment  is  attended  with  little  pain,  but 
the  process  of  inflating  the  chest  seems  rather  for- 
midable, and  most  patients  shrink  from  it.  The 
gas  is  gradually  al)sorbed,  so  that  after  a  number 
of  weeks  a  fresh  inflation  is  usually  needed.  Some- 
times three  or  four  are  required  before  the  cure 
is  complete.  The  patient  experiences  after  the  in- 
flation the  same  sort  of  dyspnea  that  comes  when 
a  pneumothorax  occurs  suddenl)-;  1)ut  this  is  rarely 
severe  enough  to  make  it  unsafe  for  the  physician 
to  do  the  operation  in  his  oflice  and  allow  the  patient 
to  go  home  after  an  hour's  rest.     If  the  air  or  gas  is 


.The  Management  of  the  Diseased  Lung     217 

sterile,  no  infection  takes  place  in  the  pleura ;  but 
an  effusion  of  serum  is  an  occasional  complication 
of  the  treatment. 

The  necessary  instruments  are  few.  A  rather 
large  aspirator  needle  attached  to  a  long  rubber 
tube,  to  the  other  end  of  which  is  fixed  any  appara- 
tus for  drawing  air  through  a  large  tube  containing 
sterile  cotton  for  the  purpose  of  filtering  the  air, 
would  do.  A  better  plan  is  to  have  a  cylinder  of 
compressed  sterile  nitrogen  gas  that  is  let  out  into 
a  little  gasometer  of  one  or  two  quarts'  capacity, 
to  be  thence  let  into  the  chest.  By  this  means  the 
exact  amount  of  gas  introduced  can  be  measured. 
It  should  be  allowed  to  flow  into  the  chest  without 
any  special  pressure  until  the  pleural  cavity  is  fully 
inflated. 

The  needle  should  be  sterile,  and  it  as  well  as  the 
tube,  should  l)e  filled  with  the  sterile  gas ;  then  the 
needle  may  be  plunged  into  the  chest-wall  at  the 
common  point  of  election  for  aspiration  of  the  chest, 
and  deeply  enougli  to  reach  just  be3'ond  the  chest- 
wall.  A  deep  inspiration  usually  starts  the  inflow 
of  gas  and  begins  the  separation  of  the  pleural  sur- 
faces. The  instant  the  gas  begins  to  flow  rather 
freely,  the  needle  ought  to  be  pushed  deeper,  to 
make  sure  that  its  point  is  carried  fully  Ijcyond  the 
wall  of  the  chest,  so  as  to  prevent  any  subcutaneous 
emphysema  —  a  thing  that  frequently  happens.     It 


2i8  Tuberculosis 

can  be  pre\'ented  to  some  degree  by  the  after  dress- 
ing of  a  hard  pad  (a  roll  of  bandage  lying  parallel 
with  the  ribs  is  a  good  one)  held  firmly  against  the 
chest-wall  by  a  stout  bandage  around  the  body.  If 
the  needle  at  first  is  pushed  too  far,  it  will  enter  the 
lung,  draw  blood,  and  fail  to  let  air  into  the  pleura; 
then  it  must  be  withdrawn  slightly.  The  results 
of  this  treatment  are  not  all  that  was  at  first  hoped 
for  it,  l^ut  they  are  such  as  to  stamp  it  as  an  eligible 
operation,  and  to  add  to  the  proof  that  effusions 
of  serum  and  pus  in  the  pleural  cavity  had  already 
given  us  —  that  the  putting  of  a  tuberculous  lung 
to  rest  is  good  treatment  for  it. 

But  the  inflation  treatment  will  probably  be  used 
in  only  a  very  limited  number  of  cases.  It  will 
liave  to  be  restricted  to  (i)  incipient  cases  of  (2) 
one-sided  disease,  where  there  are  (3)  no  adhesions, 
where  (4)  the  patient  will  consent,  and  where  (5) 
the  doctor  is  prepared  and  w'illing  to  administer  it. 
These  conditions  restrict  the  proportion  of  cases 
greatly.  The  vast  majority  of  patients  can  never 
have  the  treatment,  and  these  require  rest  of  the 
lung  as  truly  as  any. 

We  can  put  the  lung  to  partial  rest  by  a  variety 
of  measures,  always  assuming  that  there  is  one 
sound  Iuii£j  to  breathe  with. 

One  of  these  measures  is  to  repress  cough  by 
personal  effort,  especially  the  useless  cough.     This 


The  Management  of  the  Diseased  Lung     219 

can  be  done  to  a  large  extent  by  the  wih  of  the 
patient.  He  can  try  to  prevent  the  cough  except 
when  loose  phlegm  is  present  in  the  trachea  or  large 
bronchi,  and  can  succeed  half  of  the  time ;  the  other 
half  of  the  time  he  can  prevent  the  intense,  hard 
coughing  efforts  that  are  preceded  by  deep  inspira- 
tions. The  process  is  psychologic,  and  it  will  suc- 
ceed often.  There  is  a  vast  amount  of  wholly 
unnecessary  coughing  done  by  these  patients  at  the 
l)ehest  of  tickling  sensations  in  the  throat,  which, 
if  the  cough  were  suppressed  for  a  moment,  would 
disappear.  Waiting  for  a  few  minutes,  the  phlegm 
becomes  so  loose  as  to  be  raised  by  a  slight  effort  — 
sometimes  by  the  maneuver  of  hawking.  Spraying 
the  throat  with  soothing  solutions,  as  of  a  one  per 
cent,  solution  of  carbolic  acid  and  menthol  in  albo- 
lene,  or  gargling  with  a  weak  alum  solution,  may 
help  the  patient  to  suppress  the  cough.  The  neb- 
ulizers are  better  than  the  spray  machines  for  the 
oily  medicaments,  the  particles  of  the  latter  being 
rendered  more  minute. 

Another  method  of  great  value  in  reducing  the 
labor  of  expectorating  is  to  cough  at  the  end  of  a 
profound  expiration.  Then  the  bronchi,  and  cavi- 
ties if  there  are  such,  are  partially  collapsed,  and 
through  their  narrowed  channels  a  mass  of  a  given 
size  can  be  pushed  out  by  half  the  force  of  air- 
blast   that    is    usually   required.     To  cough   at   the 


220  Tuberculosis 

end  t)f  a  deep  inspiration  is  to  increase  the  force 
and  volume  of  air  required  to  move  a  mass  of 
pbleom  toward  the  exit  (since  the  air-channels  are 
widened),  and  tul)erculous  patients  ought  to  avoid 
it  as  far  as  they  can.  Any  patient  who  will  try  the 
two  methods  alternately  and  faithfully  will  be  con- 
vinced of  the  value  of  coughing-  at  tlie  end  of  ex- 
piration, may  save  himself  considerable  discomfort, 
may  spare  his  lung-tissues,  and  thereby  favor  re- 
covery from  his  disease. 

We  ha\e  many  of  us  long  advised  patients  to 
cough,  and  to  cough  forcefully,  so  as  to  expel  the 
purulent  phlegm,  on  the  theory  that  its  retention 
produces  fever.  I  am  now  satisfied  that  this  is  an 
error,  for  pus  in  a  bronchus  does  not  to  any  extent 
cause  fever.  It  mav  be  long  retained  in  bronchiec- 
tatic  cavities  with  almost  no  fever.  The  fever- 
causing  pus  products  are  substantially  always  in 
cavities  outside  the  bronchi,  or  in  some  of  the  wall 
tissues  of  the  bronchi  themselves,  and  beneath  the 
mucous  membrane. 

Another  useful  maneux'cr  is,  while  horizontal, 
to  lie  on  the  well  side,  so  as  to  have  the  force  of 
gravity  to  fa\'or  the  flow  of  the  phlegm  toward 
the  trachea,  and  thereby  minify  the  cough.  Some- 
times a  whole  night  may  tlurs  be  spent  in  sleep 
^^•ilhnut  cougli.  tlic  discharge  flowing  liy  its  weight 
into  larger  and   larger  tubes  and   partially   drying 


The  JNlanagement  of  the  Diseased  Lung     221 


on  their  waUs  without  irritating  them.  It  is  loos- 
ened Ijy  the  activities  of  the  morning  and  the  tak- 
ing of  fluids,  which  cause  a  shght  flow  of  serum 
upon  the  mucous  membrane;  then  it  is  all  easily 
coughed  up  in  a  few  minutes.  The  mucous  mem- 
brane proximal  to  the  lung  lesion  becomes  in  a 
measure  tolerant  of  the  presence  of  this  morbid 
material,  but  the  parts  distal  to  the  lesion  are  often 
so  sensitive  as  to  provoke  a  cough  the  instant  any 
of  the  material  invades  them. 

A  general  habit  must  Ije  cultivated  of  breathing 
quietly  —  breathing  more  rapidly,  if  necessary,  but 
never  more  deeply  than  usual.  There  must  be  no 
public  speaking  or  singing,  as  these  exercises  always 
strain  the  lungs,  and  experience  shows  that  patients 
who  indulge  in  them  are  injuied  thereby.  They 
are  even  worse  than  using  the  breathing  tubes,  which 
are  sufficiently  harmful. 

The  diseased  lung  can  be  forced  into  partial 
quiescence  1)y  means  of  adhesive  bandages  applied 
about  the  chest  to  minify  the  motion  of  the  riljs 
on  the  affected  side,  with  tlie  addition  sometimes 
of  a  wide  band  around  the  abdomen  to  restrict  the 
excursions  of  the  diaphragm.  This  is  a  method 
that  has  often  Ijeen  employed  to  limit  movement 
w^iere,  from  injur}^  or  neur.nlgia  or  inllammation, 
a  side  has  been  in  pain  ;  and  for  that  purpose  it  has 
been  effecti\'e.     It   ought  to  be  employed  more  in 


222 


Tuberculosis 


diseases  of  the  lung  itself,  where  quiescence  always 
tends  toward  recovery.  When  it  can  be  carried 
out  with  some  degree  of  continuity,  it  will,  I  believe, 
materially  assist  in  the  process  of  recovery  by  short- 
ening the  disease,  lessening  the  amount  of  fibrosis, 


Fig.  3.     Strapping  the  chest  to  restrict  the  action  of  a  lung. 
(Rear  view.) 

and  reducing  the  tendency  to  amyloid  degeneration 
of  important  organs  from  prolonged  suppuration. 
It  produces  in  many  cases  marked  amelioration  of 
some  of  the  annoying  symptoms,  and  the  benefit 
is  often  instantaneous.    It  stops  the  rales  and  rhon- 


The  Management  of  the  Diseased  Lung     223 


chi  that  keep  many  patients  awake  and  annoy  them 
into  frenzy;  it  lessens  harassing  and  useless  cough, 
often  to  a  marked  degree;  it  relieves  the  sensation 
of  fatigue  in  the  side  that  many  patients  complain 
of.  They  feel  from  it  a  sense  of  support  of  the 
side  that  is  grateful. 


Fig.  4.     Strapping  the  chest  to  restrict  the  action  of  a  lung. 
(Front  view.) 

The  strapping  is  best  done  with  rubber  adhesive 
plaster,  two  inches  wide,  passed  about  the  chest 
below  the  axilla  horizontally,  and  extending  two 
or  three  inches  beyond  the  center  line  on  to  the 


224  Tuberculosis 

\vell  side.  The  lirst  strip  is  best  applied  at  the  bot- 
tom of  the  chest,  and  the  successive  ones  above  this 
slightly  overlap  each  other,  so  that  when  the  dress- 
ing is  finished  the  side  of  the  chest  is  almost  com- 
pletely covered.  The  arm  must  hang  vertical  as 
the  strips  are  applied,  for  if  it  is  elevated,  the  upper 
edge  of  the  plaster  is  almost  sure  to  cut  into  the 
folds  of  the  axilla  when  the  arm  is  brought  down ; 
and  to  cover  the  space  front  and  back  above  the 
level  of  the  axilla,  the  strips  must  be  placed  diago- 
nally, spread  out  in  a  fan-shaped  manner,  those  in 
front  beginning  over  the  upper  end  of  the  sternum 
and  ending  below  the  scapula  of  the  well  side,  those 
in  the  back  starting  over  the  interscapular  space 
of  the  well  side  and  terminating  beyond  the  ensi- 
form  cartilage.  Finally,  two  strips  should  be  car- 
ried over  the  shoulder  and  brought  down  front  and 
back  to  the  lowest  edge  of  the  applied  plaster,  and 
be  pressed  firmly  against  it.  The  skin  of  the  shoulder 
is  easily  irritated  by  the  plaster,  and  would  better 
be  protected  by  a  piece  of  cloth  beneath  it,  for  it 
is  not  necessary  to  have  the  plaster  adhere  to  the 
shoulder ;  its  object  is  to  prevent  motion  by  holding 
the  shoulder  down  by  its  pull  against  the  transverse 
plaster  lielow. 

Everv  strip  of  the  plaster  nuist  be  applied  with 
the  chest  in  profound  expiration,  and,  except  over 
the  shoulder,  each  strip  should  touch  the  skin  first 
at  its  center,  the  tw^o  ends  being  then  drawn  to  place 


The  Management  of  the  Diseased  Lung     225 

at  the  same  instant  and  pressed  firmly  until  their 
adhesive  material   has  taken  a  good  hold. 

The  plaster  remains  in  place  effectively  for  a 
variable  length  of  time,  depending  on  the  heat  of 
the  surface  of  the  body,  the  amount  of  perspiration 
and  oil  on  the  skin,  the  condition  of  the  skin,  and 
probably  on  other  and  not  well-known  conditions 
as  well.  Usually  it  requires  to  be  taken  off  and 
replaced  at  the  end  of  about  a  week.  By  that  time 
the  plaster  has  crept  a  little,  and  its  tissue  may 
have  stretched  a  trifle  also.  The  imprisoned  skin, 
too,  has  perhaps  begun  to  show  some  irritation.  .\ 
few  pimples  and  spots  of  excoriation  may  have  ap- 
peared, and  the  patient  may  have  been  annoyed  by 
itching. 

Dr.  Charles  Denison  has  suggested  ingeniously 
that  the  shoulder  of  the  well  side  be  made  a  fixed 
point  of  attachment  for  the  narrow  ends  of  plasters, 
which  are  made  some  six  inches  wide  at  the  part  that 
covers  the  diseased  side.  This  ought  to  prevent 
some  of  the  creeping  of  the  plaster ;  and  experience 
may  show  that  the  method  will  l)e  tolerated  well  by 
the  patient. 

iVfter  the  plaster  has  been  removed,  some  simjile 
dusting  powder  may  be  applied  for  a  day  or  two 
if  the  irritation  is  at  all  severe,  when  fresh  i^laster 
should  be  put  on  again,  and  so  on  for  many  months. 
The  skin,  after  the  first  few  applications  of  the 
plaster,  may  grow  tough,  so  that  the  annoyance 
15 


226  Tuberculosis 

is  much  reduced.  But  if  the  tendency  to  irritation 
persists,  an  adhesive  plaster  containing-  some  oxide 
of  zinc  may  be  used.  This  seems  to  agree  with 
a  vulnerable  skin  better  than  the  unmedicated  plas- 
ter, although  it  is  rather  more  yielding.  In  remov- 
ing the  plaster  the  least  discomfort  is  produced 
when,  after  cutting  the  shoulder  strap,  the  whole 
mass  is  peeled  off  together,  beginning  at  the  front 
edge  and  pulling  back  along  the  surface  of  the 
body,  and  not  at  right  angles  to  it.  A  quick,  firm 
pull  startles  the  patient  a  trifle,  l^ut  really  causes 
less  discomfort  than  taking  the  plaster  off  slowly. 
When  abdominal  breathing  is  extensive,  the  effect 
of  any  fixation  of  the  ribs  by  the  plaster  may  be 
almost  neutralized  by  the  vertical  motion  of  the 
lung.  Then  a  rather  firm  bandage  for  the  abdomen 
will  be  necessary ;  but  as  most  patients  breathe 
almost  wholly  with  the  thorax,  this  will  not  often 
be  required.  For  the  purpose  any  simple  firm  cloth 
will  do,  w'hen  pinned  at  half  a  dozen  points.  It 
does  not  seriously  embarrass  the  al)doniinal  organs 
unless  there  is  inflammation  or  tuberculosis  w'ithin 
this  cavity.  E\en  when  the  diaphragm  is  fixed  or 
almost  motionless,  fixation  oi  the  ribs  of  one  side 
l)y  any  means  whatever  cannot  completely  put  the 
lung  at  rest,  since  the  mediastinum  will  move  slight- 
ly with  each  movement  of  the  other  side  of  the 
chest ;  Init  this  is  only  a  slight  drawback  to  the 
value  of  the  method  here  described.     If  it  were  not 


The  ]\lanagement  of  the  Diseased  Lung     227 

for  the  annoyance  the  plasters  give  the  skin,  I  feel 
certain  that  this  means  of  lung  fixation  would  come 
into  general  use  in  unilateral  cases  of  consumption. 

A  better  fixation  apparatus  is  a  perfectly  fitting, 
unyielding  jacket  or  splint  embracing  one  side  of 
the  chest.  When  accurately  applied  and  well  fitted 
to  the  chest,  it  materially  reduces  motion,  and  is  so 
far  a  most  useful  device.  It  has  the  advantages 
that  it  does  not  irritate  the  surface  and  that  it  main- 
tains a  uniform  degree  of  pressure  continuously. 
Its  drawbacks  are :  some  difficulty  in  having  it  well 
made  and  properly  fitted ;  the  repeated  tinkering 
often  required  before  it  will  fit  firmly  without  an- 
noying some  part  or  spot ;  some  nervous  discomfort 
for  a  few  days  from  a  sense  of  imprisonment  on 
beginning  to  wear  it ;  and  at  first  the  annoyance 
at  having  to  wear  it  at  night  —  for  it  ought  to  be 
kept  on  constantly,  or  nearly  so,  to  have  the  best 
effect.  A  little  patience  and  perseverance  usually 
remove  all  these  obstacles  in  a  few  days. 

The  apparatus  may  be  made  of  any  liglit  material, 
as  thick  leather  or  yucca  wood,  supported  and  kept 
in  position  by  stout  steel  bands,  which  may  be  bent 
to  fit  the  body  after  the  manner  of  the  steel  of  a 
truss.  A  plaster  cast  of  the  chest  is  necessary  over 
which  to  fit  the  splint ;  such  a  cast  helps,  but  can 
never  enable  one  to  make  a  perfect  fit  for  the  chest 
in  life  and  activity.  More  or  less  adjustment  will 
probably  always  be  necessary  after  the  instrument 


228 


Tuberculosis 


is  made,  before  it  is  both  efficient  and  comfortable. 
Once  adjusted  properly,  it  can  be  worn  for  months 
without  change. 

No  one  but  a  superior  Ijrace-maker  is  capable  of 
fitting-  successfully  such  an  apparatus  as  is  here 
described. 


Fig.  5.  Author's  jacket  for  reducing  the  motion  of  one 
side  of  the  chest  (made  by  the  W.  W.  Sweeney  Co.,  Los 
Angeles,   Cal.). 

This  jacket  is  best  worn  over  a  smooth-fitting 
undergarment,  which  should  be  changed  frequently. 
Even  then,  perspiration  will  sometimes  dampen  the 
lining  of  the  apparatus,  and  it  is  sure  to  have  at 
times  a  musty  or  sour  odor.  This  can  be  corrected 
any  time  by  heating  it  to  a  safe  degree  by  cautiously 


The  Management  of  the  Diseased  Lung     229 

holding  it  for  a  few  minutes  over  a  fire,  or  over  a 
kerosene  lamp  with  a  large  flame. 

Finally,  a  resourceful  patient  can  develop  the 
power  and  create  a  habit  of  repressing  to  a  moderate 
degree  the  action  of  the  muscles  of  one  lateral  half 
of  the  chest,  thereby  reducing  the  motion  of  that  side 
and  rendering  the  lung  relatively  quiescent.  It  re- 
quires for  a  time  almost  constant  minute  attention 


Fig.    6.      Author's    jacket    applied. 

to  the  subject,  a  good  deal  of  \y\\\  power,  and  a 
peculiar  mental  control  of  the  muscles,  in  order  to  be 
able  to  form  thus  a  new  habit  in  breathing.  No 
very  sick  person  has  the  power  of  attention  that  is 
required,  and  perhaps  no  one  is  capable  of  develop- 
ing the  habit  of  one-sided  breathing  to  such  a  de- 
gree as  to  carry  it  on  perfectly  in  sleep.  Probably 
few  patients  will  ever  succeed  in  using  tlic  measure 
to  any  great  effect ;  Init  the  effort  ought  to  be  made, 
and  those  who  accomplish  it  deserve  to  recover. 


CHAPTER    XIV 
TREATMENT,    CLIMATIC 

One  of  the  best  of  all  treatments  for  pulmonary 
tuberculosis  is  a  new  climate  —  and  the  best  climate 
for  the  disease.  The  best  for  the  particular  patient 
is  usually  some  other  than  the  one  in  which  he 
contracted  the  disease.  No  climate  is  exempt  from 
the  initial  occurrence  of  tuberculosis.  The  disease 
originates  in  all  the  "  resorts  "  for  its  cure.  If  any 
place  had  such  exemption,  it  would  be  the  refuge 
for  all  people  who  suppose  themselves  predisposed 
to  the  disease;  but  certain  climates  are  better  than 
others  for  patients  who  have  acquired  it,  and  such 
benefits  as  they  possess  every  patient  ought  to  have 
if  he  can.  There  is  a  good  deal  of  confusion,  both 
with  the  profession  and  the  people,  on  this  whole 
subject,  not  only  as  to  what  are  the  best  climates 
for  consumption,  but  as  to  why  and  by  what  ele- 
ments any  climate  commends  itself  as  a  residence 
for  those  who  have  the  disease.  So  far  as  our 
knowledge  goes,  there  can  be  but  a  few  elements 
involved  in  the  variations  of  climate  anywhere  in 
the  world.  It  must  be  a  matter  almost  exclusively 
of  the  atmosphere  near  the  surface  of  the  earth,  ancl 
includes   the   elements    of    temperature,    humidity, 

230 


Treatment.  Climatic  231 

weight  (Ijarometric  pressure),  motion,  and  purity 
of  the  air.  The  humidity  covers  much  of  the  ques- 
tion of  fogs  and  storms,  and  so  of  degree  of  sun- 
shine; and  weight  is  concerned  with  that  of  ahi- 
tude;  while  temperature  explains  and  defines  much 
of  the  changeableness  of  weather.  It  is  evident 
that  altitude,  latitude,  and  the  presence  of  moun- 
tains and  large  bodies  of  water  are  the  chief  factors 
that  determine  the  qualities  of  any  climate.  These 
elements  given,  and  a  careful  study  will  almost 
certainly  enable  a  student  of  the  subject  to  say  what 
the  climatic  qualities  of  a  particular  region  must 
be,  showing  that  there  cannot  be  any  very  mysteri- 
ous quality  in  any  climate.  That  is,  the  features 
of  all  climates  are  rational ;  and  it  is  rational  that 
some  should  Ije  more  and  some  less  fit  for  those 
sick  with  particular  diseases.  This  is  especialy  true 
of  pulmonary  tuberculosis. 

There  can  be  no  question  that  one  of  the  good 
effects  of  any  climate  to  which  a  consumptive  may 
go  is  its  newness  to  him,  and  his  hope  and  belief 
that  it  is  to  do  him  good.  It  is  a  change,  and  a 
change  is  per  se  beneficial.  But  there  are  certain 
qualities  of  climate  in  particular  regions  that  spe- 
cially commend  them  to  these  sick  people  and  make 
their  lot  in  li\-ing  easier.  The  one  of  chief  value  is 
mildness  —  absence  of  any  disagreeable  quality  that 
is  depressing  to  the  patient,  so  that  he  not  nnlv  can. 


232  Tuberculosis 

but  is  by  the  very  weather  invited  to,  spend  much 
of  his  time  out  of  doors.  Outdoor  hfe  is  the  most 
valuable  treatment  of  tuberculosis  extant;  hence 
any  place  where  the  weather  makes  it  easy  for  the 
patient  to  have  with  comfort  this  surpassing  remedy 
all  the  time,  is  salutary  for  this  disease.  And  1 
have  no  hesitation  in  saying  that  the  major  part 
of  all  the  benefits  of  climate  for  consumptives  is 
due  to  this  one  fact;  no  other  influence  is  at  all 
comparable  to  it. 

But  there  are  qualities  of  atmosphere  that  are 
valuable  independently  of  mildness  and  purity. 
Chief  among  them  are  the  low  barometric  pressure 
of  altitude,  and  dryness.  Low  relative  humidity  of 
the  atmosphere  has  long  been  held  to  be  beneficial 
in  consumption,  and  probably  with  good  reason. 
The  patients  do  better,  other  things  being  equal, 
in  such  climates ;  and  this  is  the  best  evidence  of 
all.  In  the  dryer  air  there  is  less  expectoration, 
at  first  proljably  due  mostly  to  reduction  of  the 
watery  elements  of  the  phlegm,  not  so  much  to  any 
decrease  in  the  pus.  If  the  pus  is  lessened  at  all, 
it  is  an  advantage,  since  the  formation  of  it  for 
long  periods  is  an  injury  to  the  system.  And  the 
reduction  of  cough  is  a  good  thing,  because  it  is 
always  more  or  less  of  a  strain  on  the  diseased  lung- 
tissue,  which  ought  to  l)e  kept  still :  if  the  cough  is 
severe,   the   strain    is  considerable,   and   constitutes 


Treatment,  Climatic  233 

an  amount  of  physical  exercise  that  tires  the  system 
and  perhaps  elevates  tem[)erature.  The  fever  should 
be  expected  to  be  higher  on  days  of  a  good  deal  of 
cough.  Reduction  of  the  cough  and  rest  of  the 
lung  and  muscular  system  tend  to  recuperation  of 
the  powers  of  the  Ijody,  and  so  less  pus  is  finally 
formed,  with  less  danger  of  injury  from  its  absorp- 
tion. 

But  not  all  of  the  benefits  of  dry  regions  can  be 
due  to  the  absence  of  humidity,  nor  are  all  the  disad- 
vantages of  so-called  bad  or  poor  climates  for  con- 
sumption due  to  the  presence  of  it ;  for  some  of 
the  latter  have  at  times  as  little  moisture  as  some 
of  the  better  ones.  The  arid  regions  of  the  United 
States  —  namely,  Colorado,  New  Mexico,  Arizona, 
and  Utah  —  are  reputed  of  great  value  for  tuber- 
culosis because  they  are  dry.  The  inland  regions  of 
Southern  California  enjoy  a  similar  reputation, 
founded  somewhat  on  their  dryness.  Patients  are 
sent  from  the  East  and  Middle  West  to  these  regions 
constantly,  esi)ecially  in  winter;  they  are  also  sent 
from  San  Francisco,  Oregon,  and  Washington. 
The  actual  humidity  in  these  dry  regions  in  summer 
is  considerably  less  than  that  of  the  Middle  West, 
but  in  winter  the  difference  is  less,  and  \'ery  little. 
The  regions  of  Lake  Michigan,  Minnesota,  and  the 
Dakotas  show  as  little  actual  moisture  in  the  air 
of  winter  as  most  of  the  arid  regions.     San  Fran- 


234  Tuberculosis 

cisco  has  less  actual  humidity  than  Southern  Cali- 
fornia, averaging  winter  and  summer,  and  in  winter 
as  little  as  many  places  in  Arizona,  New  Mexico, 
and  Colorado.  In  the  month  of  January,  for  ten 
years,  the  foot-hills  region  of  Southern  California 
had  two  grains  of  water  to  each  cubic  foot  of  air, 
and  Little  Rock,  IMemphis,  and  Norwalk  had  the 
same;  but  Milwaukee,  Denver,  Deadwood,  Santa 
Fe,  and  Las  Animas  had  only  half  as  much,  while 
Des  IMoines,  LaCrosse,  and  St.  Paul  had  even  less 
llian  half;  San  Francisco  had  the  same  as  Los  An- 
geles, while  Boston  and  Portland,  Me.,  had  40  per 
cent,  as  much.  In  July,  however,  all  the  arid  local- 
ities had  a  marked  reduction  as  compared  with  all 
regions  east  of  the  Missouri  River;  Los  Angeles 
had  25  per  cent,  more  than  San  Francisco,  but  11 
per  cent,  less  than  St.  Paul  and  Chicago. 

These  facts  show  that  there  must  be  some  quality 
of  the  arid  regions  other  than  the  actual  humidity 
that  is  important  for  the  sick.  That  quality  is  the 
low  relative  humidity,  the  low  percentage  of  actual 
saturation  of  the  air  for  a  large  part  of  the  time. 
It  fluctuates  with  the  time  of  day.  In  the  night 
and  early  morning,  with  low  temperature,  it  may 
be  90  to  100  per  cent.,  while  during  the  day  and 
evening,  with  higher  temperature,  it  may  be  only 
60  to  80  per  cent,  of  saturation ;  yet  the  difference 
in  the  amount  of  water  per  cubic  foot  of  air  may  be 


Treatment,  Climatic  235 

only  the  fraction  of  a  grain,  the  increase  Ijeing  in 
the  evening,  when  the  relative  percentage  is  lowest, 
and  being  due  to  increased  evaporation  during  the 
day.  Warm  air  takes  and  holds  more  moisture 
than  cold  air,  and  in  geometric  ratio  as  the  tem- 
perature rises.  The  more  moisture  the  air  takes 
up,  the  lighter  it  is ;  the  vapor  of  water  is  therefore 
lighter  than  air. 

The  thing  the  sick  need  most  is  such  a  degree  of 
humidity  and  temperature  as  will  give  most  com- 
fort, and  most  assist  the  powers  of  their  physiology, 
and  relative  dryness  often  helps  in  this  direction. 
Low  relative  humidity  seems  unavoidably  connected 
with  frequent  or  average  high  temperatures;  but 
these  latter  are  endurable  if  there  can  be  free  evap- 
oration from  the  body,  and  low  relative  humidity 
favors  this,  regardless  of  the  actual  water  in  the 
air;  for  evaporation  does  not  depend  on  how 
much  water  the  air  contains,  but  on  how  much 
more  it  can  take  and  hold.  Radiation  of  heat 
from  the  body  is  easy  with  the  temperature  at  50° 
to  70°  F. —  /.  c.  25  to  45  degrees  below  body  tem- 
perature —  regardless  of  humidity.  If  the  air  is 
nearly  saturated  with  moisture  and  not  too  warm, 
it  seems  to  our  sensations  soft  and  balmy;  with 
much  less  moisture  it  is  not  uncomfortable  and  is 
more  invigorating.  Tn  air  relatively  dry,  perspira- 
tion evaporates  rapidly  and  so  reduces  body-heat ; 


236  Tuberculosis 

with  tlie  air  at  50°  to  60°  there  needs  to  be  Httle 
perspiration  unless  there  is  free  exercise;  but,  with 
the  temperature  90''  to  100°  or  over,  the  perspira- 
tion is  profuse,  and  must  be  carried  off  rapidly  in 
order  to  keep  the  l)ody-heat  down  to  the  plane  of 
comfort;  and  if  the  air  is  near  saturation  point, 
evaporation  is  reduced  or  abolished,  and  great  dis- 
comfort as  well  as  danger  to  pulmonary  invalids  is 
sure  to  obtain. 

There  is  a  good  deal  of  fluctuation  in  relative 
humidity  at  different  times  of  the  twenty-four  hours 
in  dry  regions,  depending  on  the  temperature;  and 
the  temperature  fluctuates  greatly.  As  the  temper- 
ature falls  the  saturation  point  is  approached,  and 
it  is  often  reached  or  exceeded  for  a  short  time  in 
the  night  or  morning;  then  the  moisture  becomes 
visible  in  clouds,  fog,  or  rain.  And  in  dry  regions 
the  air  is  rapidly  chilled  by  the  most  remarkable 
radiation  of  heat  from  the  surface  of  the  earth  the 
moment  the  sun  disappears  in  cloud  or  night.  This 
phenomenon  results  from  the  marked  diathermancy 
of  the  air  due  to  its  dryness.  Moist  air  is  an  obsta- 
cle to  the  radiation  of  heat  as  well  as  to  the  trans- 
mission of  light;  the  stars  are  brightest  in  a  dry 
atmosphere. 

It  is  fortunate  that  the  highest  relative  humidity 
of  dry  countries  occurs  at  the  time  of  lowest  tem- 
perature, so  that  there  is  no  discomfort  from  heat. 


Treatment,  Climatic  237 

When  the  air  temperature  is  near  that  of  the  human 
body  or  above  it,  the  relative  humidity  is  so  low 
that  temperatures  of  5  to  10  degrees  above  the  body- 
heat  are  hardly  noticed,  so  rapid  is  evaporation  from 
the  skin.  Hence  it  is  true  that  the  perceptible  tem- 
perature of  the  air  may  be  very  different  from  that 
shown  by  the  thermometer.  In  dry  districts  the 
perceptible  temperature  is  always  below  the  reading 
of  the  instruments  on  hot  days ;  and  once  the  United 
States  Weather  Bureau  undertook  to  record  the 
range  of  this  difference,  but  it  has  been  abandoned 
as  being  perhaps  difficult  of  scientific  measurement. 
There  is  no  reason  to  think  the  daily  brief  ap- 
proach to  the  saturation  point  does  any  particular 
harm  to  the  sick,  provided  they  clothe  or  otherwise 
protect  themselves  against  the  cold;  only  they  can- 
not safely  protect  against  it  by  shutting  out  the 
fresh  air  even  if  it  be  loaded  with  fog.  The  fog- 
is  a  bugbear  to  many  sick  people,  and  there  is  a  great 
popular  prejudice  against  it;  but  it  does  little,  if 
any,  harm  if  people  will  only  clothe  according  to  the 
temperature.  Fog  may  be  disagreeable  l)y  the 
dampness  left  on  the  clfjthes  and  body,  that  must 
e\aporate  and  cause  further  coolness  as  soon  as 
the  sun  warms  the  earth ;  as  well  as  by  obscuring 
the  sun.  But  the  moment  the  fog  appears,  if  it 
occurs  in  a  warm  region,  there  is  often,  if  not  al- 
ways,  actually  less   water  present  than  there  was 


238  Tii1)erculosis 

before;  for  the  very  force  that  usually  ])rocluces  the 
fog  is  a  mass  of  cold  air,  low  in  dissolved  water, 
rushing  into  and  mingling  with  a  body  of  warmer 
air  containing  much  more  water,  so  that  the  result 
is  less  actual  humidity. 

We  ought  to  caution  all  lung  patients  in  dry  cli- 
mates to  so  clothe  themselves  at  all  times,  especially 
out  of  the  sunshine,  that  they  will  be  and  feel  warm 
constantly,  except  when  they  are  chilly  from  the 
rising  tendency  of  fever.  This  last  no  amount  of 
clothing  will  prevent ;  it  is  a  false  sensation  due 
to  tlie  pathologic  process  set  up  by  some  absorbed 
poison.  The  caution  about  clothes  is  most  needed 
by  the  ambulating  patients  who  have  but  slight 
sensations  of  cold  at  night  and  in  cloudy  weather. 
They  should  wear  all  the  clothes  they  can,  without 
positive  discomfort,  not  simply  what  they  must  wear 
or  may  think  they  need. 

A  large  amount  of  sunshine  is  desirable.  The 
patients  enjoy  it  if  the  weather  is  nut  too  hot,  and 
it  helps  to  keep  them  out  of  doors,  which  is  the 
great  desideratum.  Rainy  weather  is  objectiona1)le 
if  the  rain  continues  for  many  hours  at  a  time,  be- 
cause it  keeps  the  patients  housed,  and  prolongs 
the  period  of  atmospheric  saturation  point ;  the  for- 
mer is  bad,  and  the  latter  may  be.  That  the  latter 
is  not  necessarily  and  always  bad  is  shown  abun- 
dantly by  a  large  number  of  recoveries  from  pul- 


Treatment,  Climatic  239 

monary  tuberculusis  in  mikl  and  enjoyal)le  climates 
on  the  sea-coast,  on  islands  of  the  sea,  and  on  ship- 
board. Santa  Barbara  and  San  Diego,  in  Califor- 
nia, not  to  name  many  other  places,  have  furnished 
sufficient  examples  of  this  sort. 

While  the  balance  of  proof  is  in  favor  of  a  dry 
climate  for  consumption,  the  balance  is  not  very 
large,  for  many  patients  have  appeared  to  do  better 
in  moist  and  mild  climates  like  those  of  the  coast 
of  Southern  California  and  the  north  shore  of  the 
Mediterranean  Sea,  as  well  as  out  to  sea  in  mild 
climates.  Here  the  patients  complain  less  of  dry- 
ness of  the  respiratory  passages  and  have  less  of 
the  annoying,  dry,  and  useless  cough;  and  as  the 
mildness  permits  them  to  live  much  out  of  doors, 
they  are  able  to  have  the  greatest  benefit  of  any 
climate. 

Altitude  has  long  been  held  to  be  beneficial  in 
pulmonary  tuberculosis,  and  probably  with  good 
reason.  An  elevation  of  three  to  fi\'e  thousand  feet 
above  sea-level  often  starts  a  process  of  better  nu- 
trition in  patients  who  come  from  lower  levels. 
The  change  sometimes  begins  an  improvement  that 
goes  on  to  recovery.  The  reason  for  the  benefit 
is  a  matter  of  some  speculation.  A  favorite  theory 
long  held  was  that  the  more  rai)id  and  deeper  breath- 
ing required  by  the  rarefied  air  expanded  lung  vesi- 
cles and  so  helped  to  cure  the  disease.     But  I  be- 


240  Tuberculosis 

lie\'e  this  theory  is  untenable,  because  it  is  no  benefit 
to  tlic  diseased  lung-  tissue,  but  the  contrary,  to  have 
it  expanded  extremely.  It  is  well  established  now 
that  as  one  journeys  from  a  lower  to  a  higher  alti- 
tude the  red  corpuscles  of  the  blood  increase  in 
number,  there  heing  perhaps  a  slight  reduction  in 
their  diameter.  In  the  time  required  to  travel 
cjuickly  to  the  top  of  a  high  mountain  the  number 
increases  by  some  thousands  for  each  cubic  mille- 
meter  of  blood.  But  not  all  the  increase  shown 
l)y  the  usual  examinations  of  the  Ijlood  is  real ;  some 
of  it  is  due  to  a  rapid  flow  of  the  red  corpuscles 
from  the  deeper  vessels  to  the  surface  of  the  body.^ 
Such  rapid  changes  in  the  blood  elements  are  a 
hint  of  further  changes  as  vital  in  the  other  physio- 
logic conditions,  that  can  explain  any  l)enefit  to  the 
sick  far  better  than  a  supposititious  influence  on  the 
mechanics  of  the  lungs,  due  to  rarefied  air. 

The  cases  that  do  best  at  high  altitudes  are  in- 
cipient ones ;  more  advanced  cases  often  run  a  rapid 
course  to  death.  Where  the  lung-tissue  is  much 
crippled  by  lesions,  whether  of  infiltration,  cavities, 
or  fibrosis,  high  altitudes  are  apt  to  depress  the 
patients,  and  they  had  better  go  to  lower  levels. 
But  the  common  fear  of  hemorrhage  from  the  alti- 
tude is,  I  believe,  quite  groundless ;  bleedings  are 
as  likely  to  occur  at  sea-level  as  at  the  mountain- 
1  Campbell  and  Hoagland :  "  Tlic  Blood-count  at  High 
Altitudes,"  .Im.  Jour.  Med.  Sci,  Nov.,  1901. 


Treatment,  Climatic  241 

top.  That  is,  no  relative  increase  of  blood-pressure 
is  likely  to  occur  at  the  seat  of  lesion  because  of  the 
altitude.  When  the  blood-vessel  walls  are  invaded 
by  tuberculosis  and  become  fragile,  the  normal 
blood-pressure  will  cause  them  to  break,  and  hem- 
orrhage will  occur,  whatever  the  altitude.  Then  the 
problem  is  to  minify  the  damage  and  danger  from 
the  bleeding;  but  the  bleeding  to  some  degree  will 
be  inevitable. 

It  is  claimed  by  some  that  high  altitudes  induce 
great  nervousness  in  invalids,  and  are  for  this  reason 
objectionable;  but  I  am  satisfied  that  this  danger  is 
much  overrated.  Doubtless  such  an  effect  does  oc- 
cur to  some  patients  after  a  time,  but  it  must  be  rare, 
and  almost  solely  after  a  residence  in  the  altitude 
for  several  months  or  years.  The  greatest  benefit 
is  probably  experienced  in  the  early  months  of  resi- 
dence at  an  elevation ;  and  this  good  influence  can 
nearly  always  be  had  before  any  bad  effects  come 
to  the  nerves. 

In  the  United  States  there  is  every  variety  of 
dry  climate  and  all  degrees  of  altitude,  and  these 
qualities  are  in  many  cases  in  combination.  The 
highlands  of  Colorado,  New  Mexico,  Utah,  and  Ari- 
zona are  all  arid  to  a  remarkable  degree.  The 
mountains  of  California  are  mostly  less  dry,  but 
dryer  than  the  regions  east  of  the  Missouri  River; 
while  Arizona  and  Southern  California  have  some 
16 


242  Tuberculosis 

regions  at  or  about  sea-level,  some  above  and  some 
below  it,  that  are  as  dry  as  any  habitable  place  on 
earth.  At  the  same  time  we  have  along  our  south- 
ern Atlantic  and  Pacific  coasts  many  places  where 
a  mild  sea  climate  can  be  found  in  perfection. 
There  is  a  medium  climate,  less  dry  than  the  arid 
lands,  but  more  so  than  the  sea-coast,  with  eleva- 
tions approaching  two  thousand  feet,  that  is  grateful 
to  a  large  proportion  of  pulmonary  patients;  it  is 
beneficial  to  many  of  them  as  well.  This  is  repre- 
sented by  such  spots  as  the  Adirondacks  in  New 
York  and  the  foot-hills  of  Southern  California  from 
Pasadena  to  Redlands. 

Patients  often  dread  low  temperatures  of  winter, 
even  when  they  are  in  an  otherwise  ideal  climate. 
But  there  is  little  reason  for  the  dread  unless  they 
are  too  weak  to  endure  the  cold  under  the  condi- 
tions that  are  necessary.  It  is  easy  for  any  patient 
of  fair  vigor  to  endure  even  zero  weather,  sitting 
out  of  doors  well  wrapped  against  the  cold,  or 
asleep  in  his  room  with  his  windows  open.  The 
air  in  such  a  degree  of  cold  is  always  dry,  freer 
from  moisture  than  the  air  of  the  warm  dry  coun- 
tries, and  strong  in  oxygen  from  its  concentration 
by  the  cold.  The  only  objection  to  the  cold  is  that 
it  is  less  agreeable  and  convenient  than  the  warmer 
air,  and  requires  better  heat-producing  powers  in 
the  body.   Patients  can  be  up  and  go  about  easier  and 


Treatment,  Climatic  243 

with  more  pleasure  in  milder  weather;  it  is  doubt- 
ful that  it  is  really  any  better  for  them  than  the  cold, 
provided  that  in  the  latter  they  can  be  out  of  doors 
enough. 

In  connection  with  this  subject  there  is  one  signal 
danger  that  must  not  be  forgotten.  The  tendency 
is  always  strong  for  the  patient  and  his  friends  to 
regard  the  climate  he  goes  to  as  the  only  thing- 
necessary  for  his  recovery,  and  to  neglect  any  good, 
sustained  hygienic  care  of  himself  after  he  arrives 
there.  He  often  goes  alone,  without  friends,  lives 
among  strangers,  is  homesick,  has  no  fit  course  of 
conduct  given  him  to  follow,  and  takes  the  advke 
of  every  lay  acquaintance  he  makes,  in  the  most 
implicit  faith  that  they  know  the  right  way  and  are 
worthy  of  being  followed.  As  a  matter  of  fact, 
such  lay  advice  is  usually  the  worst  sort  of  vicious 
nonsense  that  can  be  imagined ;  as,  for  example, 
that  the  night  air  is  bad  to  breathe ;  that  the  patient 
should  not  be  out  of  doors  later  than  four  o'clock 
in  the  afternoon,  should  not  venture  out  till  eight 
o'clock  in  the  morning,  and  that  it  will  not  do  to 
have  his  room  ventilated  so  as  to  cause  a  draft  of 
air  about  his  person ;  that  he  should  take  as  much 
walking  exercise  as  possible,  and  should  not  sit 
down  out  of  doors  in  the  cool  weather  unless  in 
the  sunshine.  These  several  pieces  of  advice  are 
not  only  wrong,   unscientific,  and  harmful,   but   if 


244  Tuberculosis 

they  had  been  conceived  in  a  deHberate  intent  to 
do  the  sick  as  much  injury  as  possible  under  the 
guise  of  kindness,  they  could  not  be  more  fitly 
stated.  Such  advice  is  given  so  uniformly  and  by 
so  many  people  that  it  is  small  wonder  the  patients 
believe  it,  which  they  generally  do  unless  they  have 
been  put  on  their  guard  by  their  [)hysicians.  And 
it  is  one  of  the  curiosities  of  mind  that  among  the 
lay  people  these  errors  should  be  carried  so  faith- 
fully from  mouth  to  mouth  for  years. 

Then  the  sick,  away  from  home  and  after  climate, 
sometimes  follow  their  own  whims,  appetites,  and 
desires  so  far  as  possible,  and  are  more  concerned 
about  their  entertainment  than  for  the  things  that 
will  help  them  recover.  They  make  their  absence 
from  home  a  matter  of  sightseeing  rather  than  a 
systematic  campaign  against  tuberculosis.  As  a  re- 
sult, many  a  one  loses  half  the  good  he  might  have 
because  he  fails  to  carry  out  a  perfect  hygienic 
course  with  his  climatic  treatment.  He  goes  to  a 
climate  where  he  can  find  a  better  air  to  breathe  than 
he  had  at  home,  and  then  shuts  himself  in  a  closed 
room  and  bad  air  for  more  than  half  the  time.  If 
then  he  fails  to  improve,  he  blames  the  climate, 
and  loses  the  time  and  money  he  has  spent  so  lav- 
ishly to  get  well.  It  is  a  most  pathetic  witchery  of 
errors,  of  which  the  profession  is  not  wholly  fault- 
less. 


Treatment,  Climatic  245 

If  patients  cannot  be  provided  against  homesick- 
ness and  be  sure  to  take  all  legitimate  advantage 
of  their  time  and  opportunities  in  their  climate-seek- 
ing, they  had  much  better  remain  at  home,  where 
at  least  they  might  be  happy  and  be  kept  under 
conditions  of  good  hygiene. 

With  the  best  intentions,  and  acting  on  the  best 
of  advice,  the  patient  often  does  himself  injury  by 
occasionally  forgetting  his  rules  and  regulations. 
He  will  watch  his  regimen  and  daily  round  of  care 
of  himself  for  a  month  at  a  time,  gaining  from 
day  to  day;  then  he  will  forget  and  over-exercise 
for  a  single  hour  or  over-eat  at  a  single  meal  and 
get  indigestion,  thereby  losing  all  he  had  gained 
for  many  weeks. 

The  effect  of  good  climate  for  consumptives  ought 
to  be  added  to  —  never  take  the  place  of  —  the 
very  best  measures  of  general  management  and 
treatment,  which  should  continue  without  a  break 
for  months  and  years.  These  are  the  patients  who, 
above  almost  all  others,  cannot  afford  to  forsfet  and 
make  mistakes,  even  occasionally.  But  it  is  a  mel- 
ancholy fact  that  they  seem  fated  to  make  mistakes 
in  their  own  care,  both  frequent  and  grave. 

There  seems  to  be  something  in  the  mere  fact  of 
climate-seeking  that  tends  to  make  people  forget 
that  climate  is  not  the  only  thing  necessary  for  the 
sick.     As  a  result,  these  pe()])le  do  some  \ery  queer 


246  Tuberculosis 

and  illogical  things.  When  one  of  them  moves  to 
a  climate  thought  to  be  good  for  his  disease,  he  ex- 
pects to  experience  benefit  in  a- few  days.  If  he 
fails  of  this,  he  is  not  only  unhappy,  but  he  is  sure 
in  a  short  time  to  lose  faith  in  the  new  influence, 
and  perhaps  will  make  several  moves  in  rapid  suc- 
cession to  different  localities,  even  of  the  same  gen- 
eral climate,  always  blaming  the  one  where  he  gets 
worse  and  praising  the  one  where  improvement  be- 
gins. 

In  this  way  different  localities  acquire  reputations, 
both  good  and  bad,  which  they  do  not  deserve,  and 
patients  put  themselves  to  vast  expense  and  incon- 
venience for  nothing,  or  worse  than  nothing.  Such 
errors  could  easily  be  avoided  if  people  would  re- 
member these  most  incontrovertible  truths:  thnt 
no  sudden  marked  benefit  e\er  results  solely  from 
any  climate  whatsoever;  that  all  climatic  advan- 
tages come  slowly  through  the  months;  that  no 
relapse  or  rapid  getting  worse  ever  comes  of  the 
legitimate  effect  of  any  climate;  that  vicissitudes 
of  weather  in  any  climate  —  of  heat  and  cold  and 
wind  and  storm  —  may  any  day  harm  an  unpro- 
tected patient;  and  that  there  is  no  magic  or  medi- 
cine that  is  known  of  as  inhering  in  any  climate, 
but  only  the  possibilities  of  clean  air  to  breathe,  and 
such  physical  influences  of  air  as  may  enable  the 
normal  physiologic  jiowers  of  the  sick  to  have  the 


Treatment,  Climatic  247 

best  chance  and  the  freest  field  for  the  cure  of  the 
body  from  disease.  Nothing  is  gained  by  demand- 
ing of  climate  more  than  it  can  do.  more  than  it 
is  reasonable  to  expect  of  it.  ]\Iuch  is  lost  by  for- 
getting the  weighty  things  of  the  laws  of  human 
physiology. 


CHAPTER    XV 
TREATMENT,  MEDICINAL  AND  LOCAL 

The  medicinal  treatment  most  constantly  de- 
manded in  tuberculosis  is  that  with  tonics.  This 
is  the  best  for  nearly  all  invalids  who  are  below 
their  par  of  general  vigor,  and  most  tuberculous 
patients  are  below  it.  But  some  of  them  are  quite 
up  to  their  usual  level,  even  above  it,  when  meas- 
ured by  any  known  standard  of  physical  vigor ;  they 
are  below  simply  and  only  in  some  unmanifest 
power  of  resistance  to  the  disease  tul:)erculosis ;  they 
apparently  resist  everything  else  as  well  as  anybody 
can.  Whether  for  this  class  ordinary  systemic  ton- 
ics are  as  useful  as  for  other  patients  cannot  be 
said,  and  it  is  rather  doubtful;  but  we  do  not  know 
of  any  other  medicinal  treatment  as  useful  for  them. 

Tonics  produce  different  and  varying  effects  on 
the  several  functions  of  the  l)ody.  Some  benefit 
most  the  digestive  organs  and  improve  the  powers 
of  blood-making,  and  through  that  the  general  vigor ; 
others  appear  to  increase  the  strength  of  the  body 
directly  and  to  add  to  its  power  of  resisting  ad- 
verse influences;  others  appear  to  aft'ect  more  the 
nerve  force,  and  to  increase  mental  poise  and  the 
power  of   normal   nerve-action,   and   the  aliility  to 

248 


Treatment,  Medicinal  and  Local  249 

sleep  and  be  refreshed.  As  to  the  action  of  many  of 
them  we  are  very  ignorant,  and  perhaps  as  to  all 
of  them.  We  know  that  they  affect  different  people 
in  different  ways,  dependent  on  individual  idiosyn- 
crasies. Some  tonics  that  agree  perfectly  with  cer- 
tain persons  wholly  disagree  with  others,  and  pro- 
duce in  exceptional  cases  the  most  unexpected  ef- 
fects, both  good  and  bad. 

Tonics  differ  in  their  rate  of  action.  Some  are 
slow,  others  are  rapid.  Cod-liver  oil  —  if  it  is  a 
tonic  and  not  merely  a  food  —  is  very  slow ;  alco- 
hol, which  to  certain  patients  is  a  positive  tonic,  is 
very  rapid ;  while  iron  and  all  the  numerous  bitter 
and  other  tonics  come  in  between  in  varying  rates 
of  effect  on  the  system. 

Probably  the  tonic  that  agrees  best  with  the  great- 
est number  of  the  tuberculous  is  a  mixture  of  some 
form  of  iron  with  bitter  principles  from  two  sources 
—  the  nux  \'omica  bean  and  Peruvian  l)ark ;  and  the 
most  eligi1)le  preparation  is  a  mixture  of  iron  with 
quinin  and  strychnin.  But  the  dosage  of  these  med- 
icines as  they  are  usually  prescribed  is  not  very 
well  adjusted.  The  rjuinin  rmd  iron  doses  are  apt 
to  be  too  large,  and  the  strychnin  too  small.  (Juinin 
should  not  l)e  given  as  a  tonic,  except  for  a  few  days 
at  a  time,  in  doses  as  large  as  two  grains  three  times 
a  day;  one  grain  is.  enough,  and  half  a  grain  is 
better  if  it  is  to  be  given  long  —  and  it  is  usually 


250  Tuljcrculosis 

best  to  give  it  long  in  tuberculosis.  On  the  other 
hand,  strychnin  is  usually  given  in  doses  so  small 
that,  even  when  long  continued,  the  best  effect  is 
not  secured;  1-30  grain  is  better  than  1-60  for  brief 
medication,  and  the  latter  is  not  too  large  for  long 
continued  use.  Any  unirritating  form  of  iron  will 
do;  a  favorite  with  me  is  the  reduced  iron  (ferrum 
redactum),  but  the  citrate  and  the  peptonate  of 
iron  are  eligible,  and  perhaps  the  last  is  the  best. 
The  combination  may  be  taken  for  a  long  time  with 
benefit,  or  the  articles  may  be  given  separately  and 
be  changed  from  time  to  time. 

Arsenic  in  the  form  of  arsenate  of  sodium  is  a  safe 
medicine  and  a  tonic  for  some  patients,  and  may  be 
continued  for  a  long  time  if  it  agrees.  Cacodylate 
of  sodium  promises  to  be  a  valuable  remedy,  but 
there  are  drawbacks  to  its  use,  and  its  value  is  yet 
to  be  proved.  The  mineral  acids  are  often  useful, 
the  l)est  being  the  hydrochloric  or  the  nitrohydro- 
chloric.  One  of  these  with  tincture  of  nux  vomica 
makes  a  most  useful  aid  to  digestion  for  some 
patients  when  taken  after  eating,  especially  when 
preceded  b}^  a  moderate  dose  of  Ijicarbonate  of  so- 
dium greatly  diluted  and  taken  before  the  meal.  The 
effect  of  the  latter  is  probably,  by  neutralizing  any 
excess  of  acid  in  the  stomach,  to  facilitate  the 
exit  of  the  debris  of  a  previous  meal  into  the  duo- 
denum, preparatory  to  the  digestion  of  the  new  one. 


Treatment,  Medicinal  and  Local  251 

The  malt  preparations  have  been  greatly  lauded 
for  their  tonic  powers,  but,  except  for  their  aid  in 
the  digestion  of  starch  foods,  they  are  not  very  valu- 
able. Nor  is  cod-liver  oil  of  much  use  in  any  way. 
It  has  a  certain  food  value,  which  is  slight,  owing 
to  the  small  amount  taken,  and  the  medicinal  effect 
is  hardly  proven  to  exist.  Really  the  small  value 
that  it  possesses  is  scant  compensation  to  the  patient 
for  the  months  of  patience  he  must  exercise  in  tak- 
ing a  disagreeable  medicine.  Other  fats,  like  olive 
oil  and  butter,  are  more  agreeable  substitutes,  and 
probably  nearly  or  quite  as  useful. 

Various  aids  to  digestion  are  often  invaluable, 
as  the  pepsin  and  pancreatin  products,  the  taka- 
diastase,  diazyme,  and  similar  preparations  for  the 
starch  digestion.  Salol,  oil  of  cloves,  creasote,  guai- 
acol,  and  others  of  their  kind  have  a  certain  use- 
fulness in  prex'cnting  fermentation  in  the  intestines. 
It  is  not  proven  that  any  of  them  has  a  direct  effect 
on  or  against  the  tuberculosis.  Creasote,  guaiacol 
derived  from  it,  and  their  carbonates  have  been  used 
in  a  routine  way  by  a  large  number  of  practitioners, 
some  of  whom  believe  profoundly  in  the  beneficial 
effects  of  these  drugs.  They  have  kept  patients 
taking  such  medicines  for  months,  even  years,  and 
sometimes  in  enormous  doses  continuously.  That 
most  of  tlie  patients  have  escaped  harm  from  them  so 
generally  is  a  valuable  lesson,  but  T  am  sorry  I  can- 


252  Tuberculosis 

not  agree  that  the  tuberculosis  is  retarded  by  them 
except  as  just  indicated. 

Chlorid  of  gold  and  sodium  has  been  much  used 
in  America  in  the  general  treatment  of  tuberculosis, 
but  we  lack  evidence  that  it  acts  in  any  way  except 
as  a  moderate  tonic.  At  one  time  it  was  thought 
to  have  some  directly  antagonistic  influence  to  tuber- 
culosis, but  the  theory  is  without  proof. 

Nuclein  in  various  forms  and  nucleinic  acid  are 
worthy  of  trial  for  their  possible  power  of  increasing 
the  resisting  power  to  tuberculosis.  It  seems  to  be 
demonstrated  that  they  increase  the  white  corpuscles 
of  the  blood ;  that  they  increase  the  forces  that 
destroy  the  bacilli  in  equal  ratio  is  not  so  well  dem- 
onstrated. Many  physicians  believe  they  have  wit- 
nessed clinical  benefits  from  these  drugs,  but  no 
extensive  tests  have  been  made  with  a  large  numl)er 
of  cases,  under  circumstances  that  permit  scientific 
comparisons  with  other  treatments.  The  prepara- 
tions deserve  a  more  general  use.  They  have  the 
advantage  of  not  being  objectionable  to  the  patient 
or  harmful  to  any  of  his  functions.  My  own  pref- 
erence is  for  the  nucleinic  acid,  which  may  be  taken 
in  2  grain  doses  between  meals,  and  in  conjunction 
with  the  ordinary  tonics. 

For  the  consti])ation  laxati\'e  medicines  are  some- 
times needed;  but  they  had  best  always  be  given 
regularly,  and  in  doses  so  small  as  to  act  as  intes- 


Treatment,  Medicinal  and  Local  253 

tinal  tonics.  Among  these  the  most  valuable  are 
aloes,  senna,  cascara,  and  rhubarb.  The  doses 
sliould  be  adjusted  to  avoid  a  cathartic  effect;  and 
the  addition  to  the  laxative  mixtures  of  belladonna 
to  prevent  griping,  and  strychnin  or  nux  vomica  on 
the  theory  of  producing  some  good  effect  in  con- 
junction with  the  laxative,  is  rather  fanciful,  as 
neither  does  any  particular  good  in  this  way.  It  can- 
not be  said,however,that  they  do  any  harm,  provided 
the  laxative  is  not  required  to  be  taken  often  enough 
to  carry  so  much  belladonna  as  to  cause  constitu- 
tional effects ;  these  last  are  always  disagreeable  and 
wholly  unnecessary.  The  strychnin  with  the  laxa- 
tive is  never  enough  to  do  any  harm  unless  the  drug 
is  being  taken  independently  in  sufficient  doses.  A 
better  addition  to  the  laxative  mixture  would  be  a 
small  dose  of  capsicum  or  piperin.  The  laxatives 
act  more  or  less  as  general  systemic  tonics,  and 
there  is  no  objection  to  their  being  continued  for  a 
long  time  if  they  agree  with  the  patient. 

The  saline  laxatives  are  entirely  eligible  if  they 
fit  the  patient.  I  should  say,  however,  that  they  do 
not,  as  a  rule,  agree  as  well  as  the  vegetable  ones. 
The  most  useful  iorm  is  a  mixture  containing  the 
phosphate  and  sulphate  of  sodium  in  about  equal 
parts  with  a  quarter  of  a  part  of  bicarbonate  of 
sodium,  a  heaped  teaspoonful  of  the  mixture  being 
taken  in  a  large  draught  of  hot  water  once  a  day. 


254  Tuberculosis 

or  oftener  if  necessary,  and  half  an  hour  before 
a  meal.  Calomel  does  not  agree  with  tuberculous  pa- 
tients as  well  as  with  most  other  sick  people,  and  the 
habit  of  taking  it  in  rather  full  doses  to  "  clean  ofif  " 
a  coated  tongue  or  to  remove  feelings  of  "  bilious- 
ness," as  many  patients  do  without  advice,  is  vicious, 
for  it  fails  to  do  these  desirable  things,  and  it  does 
debilitate  the  patient  instead. 

For  the  average  patient  the  best  laxative  is  a 
large  enema  of  warm  water  t)r  warm  normal  salt 
solution ;  it  agrees  with  more  and  disagrees  wnth 
fewer  patients  than  any  drug  or  combination  of 
them.  If  this  fails  and  drainage  is  defective,  then 
laxatives  must  be  given  regularly,  and  from  among 
the  best  the  idiosyncrasy  of  the  patient  must  deter- 
mine which  is  most  adapted  to  his  case. 

Anodynes  are  occasionally  required  in  tuberculo- 
sis, especially  the  pulmonary  form,  and  chiefly  for 
two  very  particular  conditions  —  namely,  pain  and 
excessive  cough.  A  pain  that  cannot  be  quieted  by 
warmth  to  the  part,  counter-irritation,  and  rest  (or, 
if  in  the  side,  by  fixation  of  the  chest-wall  by  adhe- 
sive straps  or  bandages,  which,  if  motion  of  the 
lung  can  be  spared,  should  always  be  tried)  requires 
some  anodyne  if  the  pain  is  not  easily  bearable. 
The  most  eligible  drug  for  this  class  of  patients  is 
probably  codein  and  its  salts,  although  for  a  slight 
pain  of  evidently  temporary  character  some  of  the 


Ireatment,  Medicinal  and  Local  255 

coal-tar  preparations  often  act  pleasantly.  Opium 
and  morphin  should  be  avoided  if  possible.  The 
pain  most  likely  to  call  for  an  anodyne  is  in  the 
intercostal  nerves  or  the  pleura;  headache  is  not 
very  common;  joint-pain  is  not  infrequent,  but  is 
rarely  so  severe  as  to  call  for  an  anodyne,  provided 
the  joint  is  kept  still  and  warm.  Rather  free  coun- 
ter-irritation with  tincture  of  iodin,  croton  oil,  chlo- 
roform liniment,  ointment  of  biniodid  of  mercury,  or 
small  blisters  will  usually  relieve  the  pain  in  the  chest, 
back  or  limbs,  and  avoid  the  need  of  quieting  drugs. 
The  cough  may  require  anodyne  drugs  if  it  is 
too  violent,  if  it  is  useless  as  failing  to  bring 
up  phlegm,  if  it  tires  the  patient  greatly,  if  it  keeps 
him  awake  to  his  evident  injury,  or  if  it  is  attended 
with  much  pain.  It  is  best  to  abolish  all  cough 
that  does  not  with  fair  ease  luring  up  phlegm;  but 
drugs  should  not  be  given  until  warmth  of  the  chest 
and  neck  has  been  tried,  nor  until  the  patient  has 
done  his  utmost  to  stop  the  unnecessary  cough  by 
his  own  will-power.  These  failing,  medication 
should  be  resorted  to,  and  those  agents  used  that 
will  disturb  digestion  and  nutrition  least.  It  is 
no  harm  if  they  produce  slight  constipation  —  that 
is  easily  relieved  by  enemas ;  but  the  integrity  of 
gastric  digeston  is  a  sacred  thing  and  must  be  con- 
served to  the  utmost.  The  best  cough  medicines 
are  codein  and  heroin,  neither  of  which  is  objection- 


256  Tuberculosis 

able  to  the  average  patient  on  the  conditions  named. 
A  quarter  grain  of  codein  (or  sulphate  of  codein) 
or  a  third  as  much  heroin  will  often  produce  a  quiet 
night  for  a  patient  who  might  otherw^ise,  through 
his  cough,  lose  half  his  required  sleep,  to  his  great 
injury.  Two  or  three  doses  of  these  drugs  in  a 
night  will  be  allo\vable  if  needed. 

Occasionally  a  tickling  in  the  throat  —  /.  c.  the 
larynx  or  trachea  —  produces  a  most  vexatious 
cough  that  continues  for  an  hour.  Sometimes  this 
may  be  quieted  by  a  pungent  thing  in  the  mouth  and 
pharynx,  like  a  gargle  of  alum- water,  a  lozenge  of 
capsicum,  a  swallow  of  whiskey,  some  highly  fla- 
vored candy,  or  chewing  dry  and  swallowing  slowly 
a  half  grain  tablet  of  acetanilid.  A  spray  (to  be 
described  more  fully  later  on)  of  carbolic  acid  in 
albolene,  or  nebulized  fluid  of  this  or  some  similar 
quieting  substance,  taken  for  a  few  minutes  occa- 
sionally, will  sometimes  quiet  this  kind  of  a  cough. 
Occasionally  it  is  helped  by  applying  a  w^arm  woolen 
bandage  around  the  neck.  Very  often  at  night 
it  is  produced  by  lack  of  sufiicient  clothing  about 
the  neck,  arms,  and  shoulders  while  in  bed  ;  then 
the  remedy  is  obvious.  The  clothing  about  the 
upper  part  of  the  body  in  bed  ought  to  be  as  thick 
and  warm  as  that  worn  during  the  day  —  or  even 
to  exceed  this;  but  such  is  not  the  j^ractice  of  most 
people,  either  sick  or  well. 


Treatment,  Medicinal  and  Local 


257 


It  has  for  generations  been  fashionable  to  give 
coughing  patients  expectorant  drugs,  whether  they 
are  expectorating  freely  or  not,  whether  their  coughs 
are  tight  or  loose.  Most  of  these  drugs  are  of 
the  nauseant  or  sedative  kind,  and  calculated,  when 
given  freely,  to  produce  nausea  and  a  free  flow  of 
saliva,  and  of  serum  from  the  bronchi.  Antimony, 
ipecacuanha,  squill,  and  senega  have  been  much  used, 
apomorphin  less  so.  When  the  cough  is  "  dry," — /.  c. 
without  expectoration  and  therefore  useless  —  their 
addition  to  small  doses  of  anodyne  drugs  is  not  spe- 
cially objectionable,  provided  they  do  not  interfere 
in  the  slightest  degree  with  the  taking  of  food  or 
with  digestion.  As  a  matter  of  fact,  they  have  in 
the  past  been  used  domestically,  and  often  prescribed 
in  the  most  routine  manner,  and  used  recklessly  by 
vast  numbers  of  patients.  They  have  probably  done 
in  the  aggregate  much  more  harm  than  good  as  they 
have  been  employed.  As  a  rule,  they  had  l;etter 
not  be  prescribed,  for  they  often  do  interfere  with 
the  digestive  organs  and  probably  cause  coating  of 
the  tongue,  and  to  give  them  when  there  is  no  use- 
less cough  is  bad  ])ractice.  Nor  is  it  probable  that 
the  nauseants  assist  to  any  valuable  degree  the  effect 
of  anodynes  that  may  be  prescribed  to  quiet  a  cough. 
The  opiates  given  alone  have  substantial! \-  tlic  same 
effect  on  the  cough,  and  no  objectionable  feature  of 
the  action  of  any  of  them  is  counteracted  by  the 
nauseants  to  an  extent  that  warrants  their  use. 
17 


258  Tiil)crculosis 

Local  medication  of  the  respiratory  passages  has 
some,  but  not  great,  value.  Its  chief  good  is  to 
assuage  annoying  sensations  in  the  throat  and  tra- 
chea. Various  sprays  and  nel)ulized  or  atomized 
fluids  and  vapors  ha\-e  been  used  in  the  hope  of 
destroying  the  bacilli  in  the  lungs,  but  they  are  all 
entirely  i)()\verless  to  do  it  without  doing  mortal 
harm  to  the  jxitient.  They  may  at  times,  and  when 
used  freely,  repress  to  a  slight  degree  the  bacilli  on 
the  surfaces  that  the  medicine  touches,  but  this  can 
never  be  any  region  of  the  lungs  where  mischief  is 
going  on.  The  bacilli  that  do  harm  always  produce 
their  havoc  beneath  a  layer  of  mucus  that  no  cough- 
ing can  e\'er  carry  away  completely,  and  usually 
beneath  the  surface  of  the  mucous  membrane,  and 
no  projected  particles  of  medicament  can  ever  reach 
them  in  these  situations. 

This  form  of  medication,  however,  may  do  good 
to  the  mucous  membrane  near  the  tuberculous  lesions 
and  which  is  irritated  by  the  disease.  Often  the 
conscious  irritation  in  the  breath-passages  is  entirely 
confined  to  the  non-tu])erculous  congested  mucous 
membrane  in  the  neighl^orhood  of  the  lesions  and 
usually  proximal  to  them.  To  these  surfaces  some 
soothing  application  may  be  a  great  boon ;  it  gives 
the  patient  comfort,  and  possibly  retards  the  spread 
of  the  disease  to  adjacent  tissues. 


Treatment,  Medicinal  and  Local  259 

Such  medicines  should  be  used  whenever  they 
are  agreeable  to  the  patient  and  as  often  as  he  likes. 
The  best  of  them  are  composed  of  albolene  or  some 
similar  oily  substance  for  a  base,  and  some  fragrant 
and  agreeable  admixture  that  has  a  harmless, 
slightly  anodyne,  and  possibly  antiseptic  effect.  Of 
these  the  best  are  carbolic  acid,  creasote,  menthol, 
oil  of  cloves,  and  oil  of  pine.  A  few  drops  or 
grains  to  the  ounce  (^  to  i  per  cent.)  are  enough, 
and  the  best  apparatus  with  which  to  divide  the 
medicament  is  one  that  makes  a  cloud  of  perfectly 
nebulized  substance.  For  this  a  pressure  tank  of 
air  is  useful  but  not  indispensible;  pressure  can  be 
made  with  an  ordinary  bicycle-pump,  forcing  air 
into  a  nebulizing  jar  from  which  the  medicine  is 
carried  through  a  tube  to  the  patient's  mouth.  An 
ordinary  atomizer  of  the  best  pattern  with  an  effect- 
ive hand  bulb  will  do  in  the  absence  of  a  better 
machine;  only,  if  the  patient  is  weak,  some  other 
hand  than  his  should  work  the  bulb.  Inhalations 
of  such  medicines,  if  they  are  to  be  used  with  efii- 
ciency,  should  be  taken  frequently;  hence  it  is  neces- 
sary that  the  patient  should  have  the  proper  facilities 
himself,  and  not  be  obliged  to  go  to  the  doctor's 
office  for  the  treatment. 

Inhalation  of  the  vapor  of  soothing  or  stimulating- 
drugs  from  cotton  or  a. sponge  in  a  tu])C  with  open 
ends  or   from  an   empty  bottle  is  sometimes  both 


26o  Tul)crculosis 

agreeable  and  beneficial.     The  iodid  of  ethyl,  crea- 

sote,  carl)olic  acid,  and  eucrdyptol  are  proper.     They 

are   best    nsed    dissoK'cd    in    alcohol    or    compound 

spirits  of  ether,  and  should  not  be  stronger  than  5 

to  15  per  cent.      If  there  is  nuich  annoying  cough, 

the  ether  preparation  is  the  l^etter  excipient.     Three 

or   four  whiffs   from  the  apparatus  may  be  taken 

every  hour  during  the  day.  and  if  found  desirable, 

the  l)ottle  or  tube  may  be  left  under  the  patient's 

pillow,  uncorked,  all  night.     The  apparatus  should, 

of  course,  jje  tightly  corked  when  not  in  use.^ 

The  menthol  tuljes  so  much   used  by  inhalation 

for  their  supposed  effect  on  headache  and  common 

colds   will    fre(|uently   allay  a  tickling  sensation   in 

the  throat  if  used  rather  freely.     The  inhalation  of 

oil  of  peppermint  with  the  hope  of  destroying  the 

bacilli  of  tuberculosis  in  the  lungs,  as  recommended 

by  Carasso.  has  been  used  considerably,  and  with 

some  evidence  but   no   proof  of   its   special    value. 

It  is  not  unlikely  that  the  vapor  of  the  oil,  if  carried 

into  the  lungs  almost  constantly  from  inhalers  worn 

day  and  night    for  a  long  time,   may   destroy   the 

bacilli  on  the  very  surfaces  where  it  strikes,  but  it 

does  not  penetrate  beneath   the  surface  to  produce 

lA  good   formula  is: 

15^  Ethyl  iodid i5y> 

Eucalpytol f5V2 

Crcasotc f3i 

Compound   spirits  of  ether q.  s.  ad  5 1  •  — M. 

Sig. — Drop  in  inhaling  tube  as  required. 


Treatment,  Medicinal  and  Local  261 

any  effect,  and,  as  already  said,  it  is  there  that  the 
chief  mischief  is  always  going  on  in  pulmonary 
tuberculosis;  there  bacilli  are  multiplying  in  vast 
swarms,  to  spread  in  every  direction  where  they 
find  resistance  low  enouoh. 


CHAPTER    XVI 
TREATMENT,  MEDICINAL— (Continued) 

Tuberculosis  of  the  larynx  has  received  varied 
and  numerous  local  treatments,  most  of  which  have 
had  little  effect,  while  some  of  them  have  heen 
positively  harmful  to  a  high  degree.  In  consider- 
ing these  cases  we  should  understand,  to  begin  with, 
that  tuberculosis  of  the  vocal  cords  is  a  matter  of 
little  inconvenience  except  from  the  hoarseness  and 
aphonia;  it  is  not  i)ainful,  and  it  does  not  interfere 
with  deglutitir)n  or  in  any  way  immediately  imperil 
life;  moreover,  it  is  sometimes  recovered  from.  It 
sometimes  interferes  a  little  in  the  expulsive  cough, 
by  the  difliculty  in  closing  the  glottis  firmly  enough 
to  get  a  strong  blast  of  air;  hut  probably  no  patient 
suffers  any  evil  effects  from  retention  of  pus  in 
his  tubes  in  consequence.  On  the  contrary,  it  may 
spare  the  lungs  from  some  injury  that  might  result 
from  straining  cough. 

It  is  the  disease  of  the  arytenoicl  regions  and  the 
space  between  them,  as  well  as  the  epiglottis,  that  is 
so  grave  a  condition  in  laryngeal  tuberculosis.  This 
causes  painful  swallowing;  pain  often  when  the 
throat  is  at  rest;  and,  after  ulceration  has  come, 
sometimes   violent   cough,   even   strangling,   on   at- 

262 


Treatment,   Medicinal  263 

tempts  to  swallow.  Only  \-ery  few  people  recover 
from  this  form,  for  it  leads  to  such  resistance  to 
taking  food  as  to  amount  to  starvation  in  a  short 
time,  and  this,  with  the  poison  of  the  disease,  rapidly 
pulls  the  patient  down. 

No  local  treatment  of  the  larynx  in  any  of  these 
cases  should  be  thought  of  unless  it  promises  either 
to  relieve  discomfort  or  to  increase  the  prospects  of 
recovery.  The  severe  treatments  have  so  far  sig- 
nally failed  to  do  either.  They  consist  of  applica- 
tions to  the  ulcerous  surfaces  and  the  swollen  tissues 
about  them  of  strong  stimulating  or  cauterizing 
drugs,  the  chief  of  which  has  been  lactic  acid  in 
nearly  or  quite  full  strength;  and  the  effect  has 
almost  invariably  Ijeen  to  cause  a  great  deal  of  pain 
of  body  and  mind,  without  vStaying  the  course  (^f 
the  disease.  These  measures  have  in  the  main  been 
one  pathetic  death-tragedy,  often  prolonged,  and 
without  a  ray  of  solace  to  the  patients. 

The  indications  for  treatment  arc  to  lessen  dis- 
comfort and  to  keep  the  ulcerous  surfaces  as  nearly 
aseptic  as  possible,  so  as  to  favor  the  healing  by  the 
natural  forces.  The  former  is  fulfilled  by  sprays 
of  local  anesthetics;  tlie  latter  is  ])oorly  fulfilled  at 
best,  but  some  l)encfit  comes  from  the  use  of  sprays 
of  antiseptics.  Fortunately  these  two  indications 
are  covered  largely  by  the  same  drugs;  but  the  list 
is  small  that  can  be  used  with  safety,  for  nothing 


264  Tuberculosis 

must  1)e  employed  that  will  harm  the  system  by 
being"  absorbed  from  either  the  throat  or  the  stomach. 
All  medicaments  used  with  the  spray  are  swallowed 
to  a  certain  extent,  and  even  those  that  are  applied 
carefully  by  the  physician  are  often  swallowed.  The 
most  ideal  application  for  comfort  is,  of  course, 
cocain  (in  a  2  to  4  per  cent,  solution) ,  but  when  used 
its  dose  has  to  be  increased  rather  rapidly,  it  fails 
to  give  much  relief,  and  its  injurious  systemic 
effects  become  a  great  drawback,  Eucain  (A)  is 
a  more  eligible  agent  with  fewer  disadvantages.  It 
may  be  used  in  a  2  or  3  per  cent,  solution ;  but 
its  solutions  do  not  keep  well  and  must  be  renewed 
frequently.  Orthoform  is  better  still,  for  it  pro- 
duces very  little,  if  any,  constitutional  effect,  and  it 
has  perhaps  some  antiseptic  influence.  But  the 
orthoform  must  be  insufflated  as  a  powder,^  and 
frequently  the  patient  tires  of  the  annoyance  of  its 
use  and  complains  that  it  has  not  been  blown  upon 
the  right  place.  Tn  most  of  these  cases  it  is  better 
to  rely  on  the  slight  benumbing  effect  of  menthdl, 

'Orthoform  4  parts,  sugar  of  milk  or  powdered  acacia  i 
part,  make  an  eligilile  mixture;  hut  the  ortlioform  is  often 
used  pure,  only  it  is  liahlc  to  pack  in  the  insutTiating  tuhc. 
'I"he  hest  form  of  tuhc  is  the  ordinary  slightly  hent  one  in 
common  use  for  taking  medicine.  A  half  inch  of  its  end  is 
hent  at  a  ri.ght  angle  to  its  straight  side,  in  an  alcohol  flame, 
and  the  other  end  attached  I0  a  tuhc  of  ruhher  one  foot  long. 
The  hent  end  of  the  tuhe  is  dipped  in  tlie  powder,  and  the 
hlast  of  air  is  lilown  from  the  operator's  lips  or  from  a  hulh. 
The  hulh  is  hetter.  as  it  does  not  carry  breath-moisture  into 
the  tuhe  to  clog  it. 


Treatment,   Medicinal.  265 

carbolic  acid,  or  oil  of  cloves,  any  one  of  which 
may,  in  weak  solution,  be  sprayed  into  the  throat 
often  without  harm.  No  amount  of  these  drugs 
that  would  ever  be  swallowed  when  used  as  spray 
can  do  any  particular  harm.  The  carbolic  acid  may 
be  used  in  ^  to  5  per  cent,  solution  in  water  or 
albolene  (2  to  20  grs.  to  i  oz.)  ;  the  menthol  in  a  5 
to  10  per  cent,  solution  in  albolene;  and  the  oil  of 
cloves  in  a  saturated  watery  solution  (0.75%).  To 
give  comfort,  they  should  be  used  shortly  before 
eating;  and  they  may  also  be  used  with  safety  after 
every  meal.  Morphin  may  be  added  to  these  me- 
dicaments, but  I  think  it  is  rather  better  to  give  it 
internally  or  hypodermically  if  it  is  necessary  to 
use  it.     It  should  be  used  with  great  caution. 

There  is  one  drug  that  offers  some  hope  of  healing 
laryngeal  ulceration,  and  it  may  be  used  with  a 
spray.  That  is  the  trichlorid  of  iodin,  a  strong 
germicide  that  seems  to  penetrate  deeper  into  a 
tul)erculous  ulcer  than  any  other  non-toxic  agent, 
and  to  favor  healing.  It  may  be  sprayed  in  i-io 
to  34  of  one  per  cent,  aqueous  solution  (]/>  gr.  to 
I  oz.),  the  strength  being  increased  if  tolerance  per- 
mits. But  il  is  an  irritant  if  tbe  solution  is  strong. 
There  is  no  objection  to  using  it  frequently.  The 
drug  is  rapidly  decomposed  on  toucliing  tlic  ulcerous 
surfaces,  setting  free  iodin  and  cliloriii.  whicb  in 
their  nascent  stale  are  \crv  dcstructixe  to  niicrol)es. 


266  Tuberculosis 

The  preparation  so  readily  decomposes  that  it  is 
important  to  have  it  always  fresh  and  perfect. 

Frequently  a  patient  will  complain  of  pain  in 
the  throat,  with  swallowing  or  otherwise,  when  no 
lesion  can  be  discovered  to  account  for  it.  Then 
usually  the  trouble  is  in  the  deeper  tissues,  the 
nerves  or  muscles  of  the  tlu'oat,  and  in  pathology  is 
probably  not  unlike  the  slightly  painful  joints  so 
common  in  this  disease.  Sometimes  the  pain  is  quite 
evanescent,  lasting  but  two  or  three  days.  It  is 
sometimes  called  rheumatic,  although  probably  by 
a  wrong  use  of  the  word.  No  treatment  is  required 
for  it. 

Some  symptoms  of  tulierculosis  are  so  trouble- 
some as  to  demand  special  consideration.  The  mo$t 
constant  of  these,  if  not  the  most  portentous,  is  fever. 
It  often  occurs  in  some  \)n.vt  of  each  day  for  many 
months  together;  sometimes  it  continues  a  large 
part  of  each  twenty-four  hours.  It  is  the  one  symp- 
t(Mu  that,  more  than  any  other,  ma}^  be  depended 
on  to  re\eal  the  progress  toward  recovery  or  the 
reverse.  If  much  fever  is  present,  it  shows  there 
must  l)e  some  mixed  infection,  and  conditions  that, 
if  they  continue  long  enough,  must  wear  out  the 
patient  and  destroy  life.  But  moderate  fever  lasting 
only  a  part  of  every  day  can  be  borne  for  a  very 
long  time  with  only  slight  peril ;  nor  is  it  true,  as 
was  formerly  supposed  that  moderate  fever  is  per  se 


Treatment,   Medicinal  267 

specially  harmful.  It  is  the  thing  that  produces  the 
fever  that  does  the  great  harm  by  impeding  the 
physiologic  processes  and  bringing  on  cachexia  and 
all  the  long  train  of  conditions  that  cause  death. 

Very  high  fever  may  cause  delirium  and  uncon- 
sciousness, as  in  sunstroke;  but  such  symptoms  are 
most  unusual  in  tuljerculosis.  Occasionally  the 
patient  feels  uncomfortable  in  the  head  or  elsewhere 
during  the  highest  temperature,  and  needs  an  anti- 
pyretic. Then  antipyrin,  phenacetin,  acetanilid,  or 
some  similar  drug  may  be  used  with  caution.  The 
temptation  is  great,  especially  to  the  young  practi- 
tioner, to  treat  the  fever  actively.  But,  as  a  rule,  the 
only  treatment  that  is  useful  consists  in  sustaining 
the  powers  of  life  and  keeping  the  patient  still.  Cer- 
tainly no  antipyretic  drug  treatment  for  the  fever 
has  so  far  shown  any  power  to  stop  its  recurrence 
or  shorten  its  period  or  increase  the  prospects  of 
ultimate  recovery. 

A  few  years  ago  a  large  number  of  doctors  all 
over  the  country  found  themselves  ready  to  confirm 
somebody's  hypothesis  that  guaiacol  freely  rubbed 
into  the  skin  would  promptly  "  bring  down  the 
fever;"  they  even  reported  numbers  of  their  own 
cases  to  prove  that  such  a  result  followed.  Now 
they  have  generally  ceased  to  use  the  drug,  and  prob- 
ably regret  that  they  reported  their  cases,  and  won- 
der why  they  ever  believed  the  hypothesis.     There 


268  Tuberculosis 

was  not,  I  am  sure,  any  scientific  reason  why  they 
should  believe  in  it,  for  the  guaiacol  manifestly  had 
no  effect  on  the  temperature.  The  fever  fell  in  some 
cases  a  short  time  after  the  rul)l)ing-  was  done,  and 
fell  for  some  reason  connected  with  the  action  of 
the  fever-producing  agent  in  the  blood,  and  the 
rubbed-in  drug  got  the  credit  of  it. 

The  night-sweats  of  phthisis  are  often  a  serious 
inconvenience,  and,  according  to  popular  Ijelief,  a 
danger  as  well.  The  patient  is  sure  to  think  his 
sense  of  prostration  of  the  day  is  due  to  the  sweat 
of  the  night  before,  wholly  ignorant  that  the  high 
fever  and  profound  pus-poisoning  that  caused  the 
fever  could  have  anything  to  do  with  it. 

Great  weakness  does,  indeed,  attend  conditions 
where  profuse  sweating  occurs,  but  there  is  no  proof 
that  the  sweating  causes  it.  The  phenomenon  is  in 
some  way  connected  with  a  phase  of  infection  where 
high  fever  falls  suddenly,  and  the  sweat  comes  when 
the  temperature  drops.  The  perspiration  carries 
away  a  good  deal  of  poisonous  matter  as  well  as 
salts,  and  this  is  without  doubt  something  of  an 
advantage  to  tlie  patient  infected  by  pus  and  tuber- 
culosis. And  the  saline  matter  and  water  are  easily 
replaced  by  the  food  and  drink.  Tt  is  not  proven 
that  a  night-sweat  is  not  a  conservative  process,  to 
be  encouraged  rather  than  otherwise:  and  until  the 
proof  exists  ])hysicians  should  be  careful  to  avoid 
stnjng  and   function-disturbing  measures  to  stop  it. 


Treatment,   Medicinal  269 

The  sweat  is  disagreeable  by  the  amount  of  it,  and 
patients  think  their  night-clothes  must  be  changed 
the  moment  they  awaken  and  find  themselves  moist, 
for  fear  of  taking  cold;  but  there  is  no  danger  of 
catching  cold  so  long  as  the  body  is  warm,  nor  is 
there  need  of  changing  the  clothing  during  the  night 
except  for  sensations  of  comfort.  The  patient's 
definition  of  a  night-sweat  is  often  faulty.  He  is 
liable  to  apply  the  term  to  a  trifling  perspiration, 
mostly  above  the  waist-line,  that  slightly  moistens 
the  night-clothes.  These  minute  perspirations  are 
usually  due  to  trivial  nervous  causes,  and  they  are 
hardly  an  inconvenience  except  to  the  mind.  It  is 
the  colliquative  sweats,  which  wet  the  night-clothes 
and  the  bed-clothing  almost  to  the  dripping  point, 
and  even  moisten  the  mattress,  that  alone  ever  re- 
quire medical  treatment  for  the  relief  of  the  dis- 
comfort they  produce. 

I  am  not  satisfied  that  the  sweats  require  treat- 
ment, since  they  neither  cause  the  weakness  com- 
plained of  nor  harm  the  patient  otherwise.  And  it 
is  an  open  question  whether  we  ought,  on  the  solici- 
tation of  the  patient,  simply  for  his  comfort,  to  try 
to  prevent  the  sweats,  when  to  do  so  we  should  be 
obliged  to  give  drugs  that  disturb  the  digestion  or 
some  other  function  that  is  important  in  maintaining 
the  powers  of  life.     My  own  view  is  that  treatment 


2/0  Tuberculosis 

is  very  rarely  justified.  There  is  no  treatment  that 
is  even  fairly  efficient,  any  way;  the  best  single 
remedy  is  perhaps  atropin,  and  that  drug  is  of  ques- 
tionable value  unless  given  to  the  extent  of  produc- 
ing its  full  physiologic  effect  —  which  latter  is  dis- 
turbing both  to  functions  and  to  comfort.  The 
aromatic  sulphuric  acid  treatment  has,  I  think,  no 
effect  on  the  sweating,  although  the  drug  is  some- 
thing of  a  tonic,  and  is  therefore  unobjectionable. 
The  local  applications  are  all  useless.  When,  as 
will  occur  in  the  absence  of  treatment,  there  happens 
to  be  a  night  without  a  sweat,  the?  patient  and  his 
friends  are  very  likely,  if  any  treatment  has  been 
resorted  to,  to  attribute  the  improvement  to  it;  and 
this  is  almost  the  sole  basis  of  the  reputation  of 
drugs  and  applications  for  night-sweats. 

The  one  measure  that  the  physician  should  never 
omit  is  an  insistent  statement  to  the  patient  that  his 
sweats  do  not  harm  him  or  cause  weakness,  Imt  are 
due  to  the  cause  of  the  weakness,  which  is  another 
thing  altogether.  If  this  declaration  is  repeated 
often  enough,  the  patient  will  usually  believe  it,  and 
stop  worrying  unduly  about  his  sweats. 

Many  patients  with  tuberculosis  fail  to  obtain  the 
proper  amount  of  sleep.  They  are  kept  awake  by 
a  great  variety  of  causes,  some  of  which  were  dis- 
cussed in  the  chapter  on  the  general  principles  of 
treatment.     The  chief  causes  of  insomnia  are  cough. 


Treatment,  Medicinal  271 

fever,  sweating,  pain,  indigestion  (sour  stomach), 
constipation,  diarrhea,  and  mental  worry.  Cough 
is  the  most  potent  cause,  and  if  this  can  be  reduced 
and  any  of  the  other  existing  causes  corrected,  sleep 
usually  ensues  after  the  fatigue  of  the  day.  Obvi- 
ously, all  the  causes  named  cannot  always  be  re- 
moved, but  efforts  should  be  made  to  do  this  by 
hygienic  and  symptomatic  treatment  carried  out  in 
a  careful  and  painstaking  way.  Usually  it  is  pos- 
sible, except  in  a  few  very  nervous  patients,  to  secure 
enough  sleep  without  soporific  drugs,  but  occasion- 
ally nothing  seems  capable  of  doing  this  but  a  sleep- 
ing potion.  The  best  of  all  are  sulphonal  and 
trional,  in  the  usual  dose  of  5  to  15  grains.  Trional 
is  rather  preferable  of  tlie  two,  and  10  grains  is 
enough  usually.  But  these  drugs  should  never  be 
used  continuously  for  many  weeks  at  a  time;  their 
proper  field  is  as  an  occasional  relief.  Bromides 
sometimes  act  pleasantly,  10  to  15  grains  of  the 
sodium  salt  being  used  two  hours  before  bed-time. 
Occasionally  a  stimulant,  as  a  moderate  dose  of 
whiskey  well  diluted,  or  a  glass  of  l)eer,  will  com- 
pose a  patient  f(;r  tlie  night.  If  the  stomach  is  sour, 
a  dose  of  aromatic  spirits  of  ammonia,  well  diluted, 
sometimes  does  good ;  or  a  liberal  dose  of  bicarbon- 
ate of  sodium  may  l)e  taken  with  benefit.  For  ner- 
vousness that  prevents-  sleep,  such  nervines  as  vale- 
rian, sweet  spirits  of  nitre,  and  asafetida  ought  to 


272  Tuberculosis 

be  used  more  than  they  are  at  present,  and  in  more 
frequent  doses  than  is  usual. 

Pulmonary  hemorrhage  is  a  sym))t()m  that  always 
disturbs  and  often    terrifies    the    patient    and    his 
friends,  and  there  is  usually  an  urgent  demand  for 
something  to  stop  it.      Small  hemorrhages  are  useful 
rather   than   otherwise,   and    require   no   treatment 
beyond  carefulness  on  the  part  of  the  patient  to  avoid 
creating  an   increased   blood-pressure,   and   thereby 
perhaps  opening  larger  vessels.     The  patient  should 
keep  still,  recline  with  the  head  high,  avoid  excite- 
ment,  eat   sparingly,   avoid   constii)ation,   keep   the 
head  cool  and  the  body  and  extremities  warm,  and 
be  as  serene  as  possible  in  his  mind.     If  he  takes 
any  drug,  the  preferable  one  should  be  some  opiate 
—  that  is,  opium  or  some  of  its  preparations.     Of 
these,  morphin  is  the  best,  and  had  better  be  taken 
with  the  proper  admixture  of  atropin.      If  the  hem- 
orrhage is  at  all  free,  the  hypodermic  method  should 
alone  be  relied  upon ;    it  is  worse  than  useless  to 
depend  on  absorption  from  the  stomach  or  the  rec- 
tum in  such  cases,  for  a  quick  effect  is  imperative. 
Moreover,  in  a  se\cre  hemorrhage  the  patient  often 
vomits  a  great  quantity  of  nuicus  and  blood  before 
the  attack  is  over,  so  that  the  chances  of  any  medi- 
cine  being   absorbed    from    the    stomach    are   very 
small.      A   quarter   grain   of   morjjhin    with    1-150 
grain  of  atropin  is  a   fair  dose   for  an  adult,  and 


Treatment,   IMedicinal  273 

this  may  be  repeated  with  caution  if  occasion  re- 
quires. But  it  ought  not  to  be  given  at  all  for  a 
trifling  hemorrhage,  a  slight  spitting  of  blood  in 
occasional  mouthfuls,  unless  the  patient  is  demoral- 
ized and  frightened.  The  opiate  tranquilizes  the 
mind  and  drives  away  fright,  and  this  is  one  of  the 
cardinal  advantages  of  the  drug.  To  do  a  large 
service  physiologically  to  the  part  involved,  the  drug 
ought  to  lessen  the  blood-pressure  in  the  deep  regions 
of  the  body.  It  does  not  do  this  to  any  large  degree, 
yet  it  is  much  the  most  useful  medication  that  we 
know  of. 

The  common  habit  of  giving  ergot  in  cases  of 
hemorrhage  from  the  lungs  is  most  reprehensible, 
for  it  increases  the  blood-pressure  and  so  makes  it 
more  likely  that  a  \'essel-wall  made  fragile  by  tuber- 
culous deposit  will  rupture.  Ergot  always  increases 
the  bleeding  in  these  cases,  never  decreases  it,  yet 
by  a  sort  of  fatality  a  large  proportion  of  even 
intelligent  physicians  continue  to  use  it.  Its  use  for 
bleeding  from  the  lungs  has  been  a  sort  of  fad 
among  certain  doctors,  and  a  foolish  if  not  a  wicked 
one,  that  started  in  the  groundless  notion  that  good 
would  somehow  be  done  by  contracting  the  blood- 
vessels. But  the  vessels  whence  the  blood  comes 
cannot  contract  in  response  to  this  or  any  other  drug, 
for  their  muscular  fibers  are  powerless,  and  by  con- 
traction of  all  the  rest  of  the  vascular  system  an 
18 


274  Tuberculosis 

iucrease  of  blood-pressure  everywhere  is  produced, 
which  puts  the  diseased,  fragile  vessels  upon  greater 
strain  than  before.  There  is  in  the  whole  range  of 
professional  experience  hardly  a  more  striking  ex- 
ample than  this  of  the  frequent  prescribing  of  a 
potent  drug  with  an  effect  the  exact  opposite  of  the 
one  intended.  If  the  fad  were  less  harmful,  it  would 
be  amusing. 

From  current  reports,  some  promise  of  relief  from 
hemorrhage  seems  to  be  offered  by  suprarenal  ex- 
tract (or  adrenalin)  given  internally.  But  if  the 
purpose  sought  is  to  contract  all  the  l^lood-vessels, 
then  we  shall  probably  be  disappointed,  for  this  is 
what  ergot  does  —  to  the  increase,  not  the  decrease, 
of  the  hemorrhage.  But  possibly  this  wonderful 
substance  has  some  other  power  over  hemorrhage, 
and  is  the  great  coming  remedy. 

One  of  the  best  measures,  in  addition  to  quiescence 
and  opiates,  is  to  tie  handkerchiefs  firmly  around 
the  limbs  next  to  the  body.  This  segregates  the 
blood  to  some  degree  in  the  limbs  and  tends  to  lessen 
the  1)Iood-pressure  in  the  center  of  the  body. 

Another  measure  of  easy  application  and  great 
value  is  (if  the  lesion  is  unilateral)  adhesive  straps 
to  the  diseased  side,  to  immobilize  the  lung,  after 
the  manner  already  described.  The  straps  should 
be  numerous,  and  should  be  drawn  as  tightly  as  pos- 
sible.    Of  even   greater   value   is   inflation  of  the 


Treatment,   Medicinal 


^7o 


pleural  cavity  with  sterile  air  or  nitrogen  gas.  This 
puts  the  diseased  lung  to  complete  rest,  and  does 
it  promptly,  and  the  hemorrhage  usually  stops  at 
once.  Unfortunately,  it  is  only  in  the  rarely  excep- 
tional case  that  this  measure  will  ever  be  resorted 
to  promptly.  But  it  can  be  used  promptly  and  effi- 
ciently in  cases  without  adhesions;  for  the  simple 
device  already  referred  to  of  an  aspirator  needle 
and  tube  can  be  employed,  or  a  large  hypodermic 
needle  with  a  bit  of  cotton  wrapped  about  its  head. 
Every  physician  carries  this  instrument,  and  there 
is  no  more  harm  or  pain  in  using  it  than  in  giving 
a  hypodermic  injection.  A  good  way  is  to  insert 
the  needle  at  a  point  least  likely  to  encounter  adhe- 
sions —  as  far  away  from  the  lesion  as  possible  — 
and  leave  it  there  for  a  few  minutes,  gently  changing 
its  depths  in  the  body  from  time  to  time,  till,  if 
possible,  the  inspiratory  movements  of  the  patient 
shall  begin  to  suck  air  into  the  pleural  cavity.  Then 
the  needle  should  be  pushed  far  enough  to  be  sure 
that  it  has  passed  clear  beyond  the  chest-wall  and 
free  into  the  pleural  cavity. 

If  the  temperature  is  high  at  the  time  of  a  bleed- 
ing, it  should  be  promptly  brought  down  with  anti- 
pyretics, and  if  the  pulse  is  hard  and  full,  aconite 
and  veratrum  may  l)e  justifiable  for  their  effect  on 
the  heart's  action  ■ —  not  to  lower  the  temperature, 
for  they  do  not  produce  this  effect. 


2'](^  Tuberculosis 

In  case  of  a  \'ery  large  hemorrhage  the  pulse 
should  be  \vatched  carefully,  and  if  it  becomes  very 
faint,  hypodermoclysis  of  normal  salt  solution  ought 
to  be  resorted  to  promptly.  The  best  place  to  intro- 
duce the  tluid  is  in  the  subchuicular  region ;  and  for 
apparatus  an  ordinary  fountain  syringe  and  an 
aspirator  needle  from  the  physician's  pocket  case 
constitute  the  necessities.  The  syringe  can  be 
cleansed,  if  necessary,  with  scalding  water,  and  the 
needle  may  be  held  for  a  moment  in  a  gas-flame 
or  over  a  lamp-flame;  the  apparatus  is  then  ready. 
The  solution  may  be  quickly  strained  through  a 
clean  cloth  or  a  bit  of  sterile  cotton  as  it  passes  into 
the  bag.  The  solution  can  be  made  in  an  instant 
with  a  heaped  teaspoon ful  of  table-salt  to  a  quart 
of  any  drinking  water,  preferably  that  which  has 
been  boiled,  although  that  is  not  indispensable.  This 
mixture  is  not  exactly  the  equivalent  of  the  water  of 
the  blood.  Imt  it  is  near  enough  for  all  physiologic 
purposes. 

The  custom  is  to  heat  the  solution  to  loo'^  F.  or 
over  before  putting  it  in  the  bag,  in  the  expectation 
that  it  will  pass  through  the  needle  at  a  temperature 
not  below  that  of  the  body.  But  this  end  is  very 
rarely  attained ;  the  solution  passes  so  slowly  that 
when  it  enters  the  tissues  its  temperature  is  often 
only  85°  or  90°  F.  A  much  better  way  is  to  pour 
the  unheated  solution  into  the  bag,  and  then  to  im- 


Treatment,   Medicinal  277 

merse  a  coil  of  the  tube  (near  the  needle)  in  a  dish 
of  hot  water  containing  at  least  a  quart.  This  water 
should  be  renewed  as  often  as  it  gets  cool. 

The  hypodermoclysis,  while  necessary  at  times  to 
save  life,  may  undoubtedly  be  carried  so  far  as  to 
increase  the  blood-pressure  to  the  danger  point. 
This  we  should  be  careful  to  avoid.  Remember  that 
it  is  desirable  that  the  pulse  should  become  weak  and 
the  blood-pressure  low ;  for  in  these  conditions  is 
the  greatest  hope  of  a  firm  and  obliterating  blood- 
clot  at  the  bleeding  point. 


CHAPTER   XVII. 
SPECIAL  TREATMENTS 

Under  the  name  "  serums  "  are  included  a  num- 
ber of  substances  that  have  l)een  used  for  tubercu- 
losis, and  which  have  their  origin  either  in  the  tuber- 
cle bacilli  directly  or  in  the  bodies  of  animals  in 
some  way  treated  with  the  products  of  tl:e  bacilli. 

One  of  these  is  the  so-called  horse  scrum,  which 
is  the  blood-serum  of  the  horse  after  the  animal  has 
been  treated  by  repeated  hypodermic  injections  of 
tuberculin.  The  theory  is  that  by  this  treatment 
there  is  developed  in  the  animal's  blood  an  anti- 
toxin to  tuberculosis,  after  the  manner  of  the  diph- 
theria antitoxin  which  has  been  so  successfully  used 
against  that  disease.  There  is  much  to  justify  such 
a  theory.  The  serum  is  used  hypodermically,  and, 
unlike  that  for  diphtheria,  which  is  rarely  used 
beyond  the  second  or  third  dose,  it  is  given  in  a 
dose  so  small  as  not  to  produce  fever,  and  repeated 
daily  or  every  second  day  for  a  long  time.  It  is 
usually  injected  into  the  back,  deeply  ])eneath  the 
skin,  in  doses  of  lo  to  15  drops.  It  produces  some 
local  swelling  and  inflammation,  and  in  susceptible 
patients  occasionally  a  small  abscess.  Some  ])e()ple 
ha\'e  a  good  tolerance  for  it,  and  take  a  large  number 

278 


Special  Treatments  279 

of  injections  with  little  complaint  or  discomfort. 

Occasionally  a  disagreeable,  if  not  dangerous, 
nervous  shock  is  produced  by  the  injections  of  horse 
serum.  It  occurs  one  or  two  minutes  after  an 
injection  has  been  taken.  Its  symptoms  are  pain  in 
the  abdomen,  general  discomfort,  flushed  face,  and 
a  feeling  of  great  fear  and  apprehension,  all  of  which 
pass  off  in  a  few  minutes.  If  the  dose  of  the  serum 
is  too  large,  it  is  sure  to  cause  fever  for  a  few  hours. 

The  experience  with  this  serum  has  not  been  very 
satisfactory.  Some  practitioners  have  reported  good 
results,  others  remarkable  ones,  and  still  others  bad 
or  indifferent  ones.  The  testimony  has  been  so  vari- 
ous and  contradictory  that  it  is  difficult  to  determine 
just  what  the  effect  upon  the  sick  has  been.  Cer- 
tainly no  obser\'er  has  recorded  results  based  on  the 
use  of  the  serum  in  a  large  series  of  cases,  under 
control  with  another  series  of  similar  cases  managed 
in  an  identical  way  with  the  single  exception  of  the 
omission  of  the  serum.  Until  such  records  are  made 
we  cannot  be  said  to  have  any  scientific  data  on 
which  to  base  definite  conclusions  as  to  the  effect  of 
this  agent. 

On  the  lower  animals,  especially  guinea-pigs, 
really  scientific  observations  have  been  made,  show- 
ing that  when  treated  with  the  horse  serum  an  ani- 
mal's life  after  inoculation  with  human  tuberculous 
sputum  is  considerably  prolonged  over  that  of  the 


28o  Tuberculosis 

control  animals.  This  seems  to  be  the  uniform 
result  of  laboratory  tests.  Yet  the  results  of  the 
use  of  the  serum  on  human  beings  at  the  hands  of 
careful  observers  has  not  been  more  than  slightly 
beneficial.  And  the  good  results  reported  have  in 
every  instance  been  based  on  the  observation  of  a 
few  patients,  without  controls  for  comparison,  and 
therefore  with  no  means  of  knowing  positively  that 
they  would  not  have  done  as  well  without  the  serum. 

I  have  repeatedly  employed  this  serum,  sometimes 
with  apparent  good  effect,  and  see  no  objection  to 
its  cautious  use  in  any  case  where  it  produces  no 
special  discomfort  or  phlegmons  or  other  terror  to 
the  patient,  and  provided  always  that  no  other  ele- 
ment of  the  best  treatment,  hygienic,  sanitary,  or 
medical,  is  omitted  in  the  slightest  degree.  This 
last  condition  is  one  that  is  usually  forgotten  and 
for  this  reason  the  t<^tal  result  of  the  scrum  treat- 
ment of  all  kinds  and  forms  has  been  probably  a 
little  less  than  nothing  of  value.  The  belief  that 
the  serum  will  somehow  cure  the  disease  absolutely, 
and  that  notliing  else  need  be  thought  of,  is  a  maggot 
that  gets  into  the  heads  of  many  of  the  patients  and 
some  of  the  physicians,  to  the  great  injury  of  the 
prospects  of  recovery. 

Tuberculin  and  sex'eral  modifications  of  it  have 
been  used  rcmedially  with  more  or  less  ajjparcnt  and 
alleged    success.     In    doses   of    i    milligram   given 


Special  Treatments.  281 

hypodermically,  it  usually  causes  fever  in  a  tuber- 
culous patient  who  is  not  in  extreme  cachexia  and 
whose  disease  foci  are  not  yet  completely  encysted. 
When  tuberculin  is  used  therapeutically,  it  is  given 
in  doses  so  small  as  not  to  produce  fe\'er,  and  re- 
peated every  few  days.  After  a  few  injections  a 
tolerance  of  it  is  developed  to  some  degree,  so  that 
the  dosage  can  be  increased  somewhat.  The  theory 
of  its  use  is  that  it  adds  to  the  tuberculin  in  the 
blood  and  dexelops  in  the  patient's  body  a  resisting 
power  to  the  disease  greater  than  existed  before. 
But  the  theory  is  unsatisfactory,  as  the  effects  of 
the  tuberculin  are  neither  uniform  nor  convincing. 
The  lymph  has  been  used  persistently  by  a  few 
practitioners  who  believe  they  have  observed  good 
results.  By  the  majority  it  has  been  condemned  as 
not  only  useless  but  harmful,  and  they  have  refused 
to  even  try  it.  They  have  argued  that  the  patient 
is  daily  casting  quite  enough  tuberculin  into  his  blood 
and  tissues  from  the  cultures  of  his  own  disease, 
and  that  no  good  can  come  of  increasing  the  amount 
But,  on  the  other  hand,  much  of  the  auto-developed 
tuberculin  is  absorbed  in  conjunction  with  pus- 
products  which  probably  retard  the  antitoxic  ])Ower 
of  the  tuberculin.  Moreover,  to  increase  the  tuber- 
culin in  the  blood  beyond  the  quantity  made  by  the 
disease  may  produce  and  increase  some  antitoxin 
for  the  tuberculosis. 


282  Tuberculosis 

Unfortunately,  the  use  of  tuberculin,  except  for 
diagnostic  purposes,  has  been  open  to  the  same  sort 
of  objection  as  that  to  the  horse  serum.  It  has 
been  used  on  a  few  cases  only,  and  the  results  have 
probably  not  warranted  either  the  extravagant 
claims  for  or  those  against  it.  The  most  thorough 
test  yet  made  in  America  is  probably  that  of  Dr. 
Trudeau.  His  trial  of  it  extended  over  a  number 
of  years,  and  was  scientific  and  fair  in  every  way. 
His  records  show  that  those  treated  with  the  lymph, 
by  comparison  with  other  similar  cases  treated  witli- 
out  it,  did  better  by  a  small  percentage.  But  he  says 
that  the  benefit  shown  was  "  not  sufficiently  marked 
to  be  in  any  way  conclusive."  All  the  experience 
with  this  agent  seems  to  show  that  under  proper 
precautions  it  is  devoid  of  danger,  especially  in  cases 
with  a  fair  degree  of  vigor  —  and  it  should  never  be 
used  in  any  other  cases.  That  being  true,  there 
is  no  reason  why  it  should  not  be  used  more  exten- 
sively. There  are  several  conditions  that  should  be 
insisted  on  if  one  is  to  use  it  therapeutically.  The 
dose  must  be  so  small  as  to  produce  only  slight  local 
reaction  in  the  form  of  moderate  congestion  of  the 
diseased  area,  never  constitutional  reaction  to  the 
extent  of  distinct  fever.  This  practically  rules  out 
all  advanced  cases  with  mixed  infection,  and  restricts 
its  use  to  the  early  and  mostly  non-febrile  cases. 
It  is  necessary  to  begin  with  a  small  fraction  ( r-ioo 


Special  Treatments  283 

to  1-150)  of  a  milligram  for  a  dose,  and  repeat  it 
rather  often,  every  two  or  three  days,  increasing  the 
dose  as  tolerance  is  established,  gradually  lengthen- 
ing the  intervals  and  giving  always  the  largest  dose 
possible  short  of  producing  febrile  reaction.  The 
injections  are  least  likely  to  produce  phlegmons 
when  made  deeply  beneath  the  skin. 

After  marked  tolerance  to  tuberculin  has  been 
established  —  which  never  occurs  until  it  has  been 
used  for  several  months  —  it  is  a  good  plan  to  stop 
its  use  for  some  weeks,  and  resume  it  later.  But  it 
will  then  be  discovered  that  some  of  the  tolerance 
has  been  lost,  and  it  will  be  necessary  to  start  again 
with  smaller  doses.  Then,  after  having  the  treat- 
ment worked  up  to  the  maximum  dose,  it  will  be 
well  to  omit  it  again  and  resume  it  later,  and  so  on 
as  long  as  there  seems  to  be  any  hope  of  its  doing 
good. 

Koch's  tuberculin  T.  R.  may  be  used  in  the  same 
way  as  the  ordinary  tuberculin,  only  in  slightly 
smaller  doses.  I  am  not  aware  that  it  has  been 
proven  to  have  any  therapeutic  superiority  over 
pure  tuberculin,  while  it  is  distinctly  more  likely  to 
produce  irritation  at  the  point  of  injection.  Injec- 
tions of  tul)erculin,  when  made  deeply,  very  rarely 
cause  any  inflammatory  action  at  the  point  of  injec- 
tion. 

Several  modifications  of  tul)crcuhn  have  been  used 


284  Tuberculosis 

besides  the  T.  R.  product.  One  is  known  as  anti- 
phtliis'ui,  and  is  said  to  consist  substantially  of  tuber- 
culin that  has  been  treed,  by  some  chemical  process, 
of  a  part  or  all  of  its  fe\-er-pro(lucing  ingredients. 
It  is  uscfl  by  the  hypodermic  method  very  much  as 
other  serums  are,  and  may  be  useful  in  some  such 
way  as  the  tuberculin  is,  luit  we  lack  as  yet  any 
definite  scientific  proof  of  its  value. 

The  fubcrciilocidiu  of  Klebs  is  the  same  as  anti- 
phthisin,with  the  addition  of  some  kind  of  an  extract 
of  the  bacilli.  This  is  more  likely  to  be  useful  than 
the  antiphthisin,  but  its  value  is  based  on  the  same 
sort  of  observation  as  that  of  the  other  agents. 
Klebs  Ijelieves  that  this  substance  is  absorbed  as 
well  from  the  rectum  as  from  beneath  the  skin,  so 
he  uses  it  by  this  and  the  hypodermic  method  indif- 
ferently, in  doses  of  10  to  15  drops  hypodermically, 
or  a  quarter  as  much  more  injected  into  the  rectum. 
In  using  it  in  this  latter  way  it  should  be  diluted 
with  2  or  3  drams  of  water,  and  taken  after  the 
bowels  have  been  evacuated,  so  as  to  insure  the 
most  complete  absorption. 

Von  Ruck  has  used  extensively  his  zcotcry  extract 
of  tubercle  bacilli.  He  believes  it  to  be  much  more 
efficacious  than  any  form  of  tuberculin.  A  few  phy- 
sicians have  used  it  and  testify  to  its  value.  I  hope 
it  is  as  valuable  as  they  think,  and  believe  it  deserves 
an  extensive  trial  in  comparison  with  pure  tuber- 


special  Treatments  285 

ciiliii.  But  so  far  as  I  am  aware,  no  such  scientific 
comparison  has  been  made  with  series  of  cases,  as 
none  has  been  made  with  it  and  under  control  of 
non-serum  cases.  Until  such  tests  are  made  we 
cannot  speak  with  any  degree  of  positiveness  of  the 
value  of  these  or  any  similar  remedies. 

Any  physician  who  will  treat  with  a  particular 
serum  every  alternate  case  that  comes  to  him,  record- 
ing the  others  as  controls,  and  managing  all  the 
cases  otherwise  in  the  same  way  in  every  particular, 
will,  when  his  cases  reach  a  hundred  or  tw^o,  have 
something  of  value  to  say  to  the  waiting  profession 
and  to  an  army  of  tuberculous  patients.  Our  mis- 
fortune, if  not  our  fault,  has  been  that  we  have 
mostly  let  our  enthusiasm  run  aw^ay  with  our  science, 
and  been  content  to  believe  or  guess  that  a  serum 
w^as  good,  and  so  have  used  it,  chiefly  without  con- 
trol or  system,  and  on  cases  likely  to  recover  by  rest 
and  good  hygiene.  By  thus  having  nothing  j^roven 
we  have  thrown  doubt  and  discredit  on  the  whole 
subject,  and  have  not  added  anything  to  the  knowl- 
edge of  the  world. 


CHAPTER  XVIII 
SANATORIA   FOR   TUBERCULOSIS 

Sanatoria  for  tuberculosis  have  many  advan- 
tages for  the  treatment  of  cases  over  any  sort  of 
home  management. 

Tuberculosis  is  a  type  of  the  long  continuing  dis- 
eases. Depending  on  the  tissue  attacked  and  on 
the  resisting  power  of  the  patient,  the  disease  lasts 
from  a  few  days  to  many  years,  and  in  hopeful 
cases  the  great  desideratum  is  for  means  to  combat 
it  in  a  persistent  campaign,  for  several  years  if  need 
be,  without  a  break  in  the  perfect  continuity  of  its 
strenuous  tension.  There  must  he  no  relaxation  of 
watchfulness  to  prevent  surprises ;  no  lessening  of 
the  resisting  forces  by  unsanitary  conditions  of  life 
that  would  lower  the  vitality  of  the  factors  of  de- 
fence. There  must  be  no  sleeping  on  watch  in  this 
camp,  nor  dissipating  of  powers  by  unwholesome 
pleasures,  nor  engaging  in  industries  not  necessary 
to  the  perfection  of  the  bodily  forces  as  a  power  of 
defence.  And  there  must  be  no  loopholes  in  the 
lines  of  resistance,  for  the  enemy  is  one  that  never 
sleeps  nor  rests  wherever  it  can  find  physical  con- 
ditions adapted  to  its  work;    it  requires  no  intelli- 

286 


Sanatoria  for  Tuberculosis  287 

geiice,  but  works  with  the  precision  and  fate  of  an 
automaton. 

For  such  a  campaign  against  this  disease  the 
prospects  of  uhimate  success  are  best  when  it  is 
conducted  in  a  chmate  best  adapted  for  it,  under 
residential  conditions  most  fit,  and  under  the  care 
and  observation  of  experts  in  this  sort  of  a  campaign, 
who  are  not  likely  to  relax  their  watchfulness  or 
lose  their  wisdom  about  it  from  one  year's  end  to 
another. 

These  conditions  are  in  the  average  case  best  at- 
tained in  sanatoria  for  tuberculosis.  This  truth  is  so 
plain  as  to  be  really  self-evident.  It  is  a  truth  that 
needs  no  argument  that  these  best  conditions  can  he 
found  neither  in  the  average  household  nor  in  the 
routine  of  the  life  of  the  average  patient.  A  few  pa- 
tients of  unusual  self-control  and  wisdom,  whose 
families  and  attending  nurses  and  friends  have  sense 
and  decision,  and  who  have  the  means  of  surround- 
ing themselves  with  all  the  comforts,  can  do  as  well 
or  even  Ijetter  than  at  the  best  sanatoria ;  but  these 
are  rare  exceptions. 

The  allurements  of  business  and  pleasure  and 
of  social  dissipations;  the  temptations  of  appetite 
and  the  fashions  of  eating,  of  dress,  and  of  social 
usages;  the  love  of  travel  and  the  desire  to  roam 
from  place  to  place — 'putatively  for  health,  but 
mostly   for   mental   diversion, —  these   are   dangers 


288  Tuberculosis 

that  handicap  most  patients  with  chronic  tubercu- 
losis who  live  at  home  or  outside  of  an  institution. 
'J1iey  follow  their  inclinations  chiefly,  and  try  to 
carry  out  the  advice  of  their  doctors  somewhat.  Too 
often  the  sole  advice  that  is  followed  is  confined  to 
the  taking  of  some  drugs,  and  perhaps  residence  in 
a  particular  place.  If  the  doctor  gives  minute  direc- 
tions in  all  particulars  necessary  to  accomplish  the 
best  effects,  the  patient  usually  finds  that  they  are 
so  radical,  and  so  completely  change  all  the  habits 
and  regimen  of  his  life,  as  well  as  perhaps  his  occu-' 
pations,  that  he  is  apt  to  think  them  unnecessary 
and  fussy,  and  to  be  ready  to  neglect  most  of  them. 
In  a  sanatorium  he  finds  it  easy  to  follow  all  of 
them,  for  there  it  is  the  fashion  to  do  this;  there 
is  no  temptation  to  the  contrary,  and  the  new  life  and 
novel  regimen  furnish  both  occupation  and  amuse- 
ment. 

The  sanatorium  for  tuberculosis  is,  in  .\merica,  a 
relatively  new  idea ;  until  recently  it  has  been 
unfashionable,  and  people  have  even  dreaded  the 
thought  of  going  to  such  an  institution  or  having 
their  friends  go  there.  They  have  hated  hospitals 
of  all  kinds,  and  in  a  blind  and  foolish  way.  For- 
tunately, during  the  past  few  years  the  value  of 
sanatoria  and  of  expert  care  for  such  cases  has  come 
to  be  better  understood  and  appreciated.  Such  insti- 
tutions, until  recent  years  confined  to  one  or  two 


Sanatoria  for  Tuberculosis  289 

in  number  (that  of  Dr.  Trudeau  at  Saraiiac  Lake, 
New  York,  easily  being  the  pioneer,  to  the  great 
credit  of  its  creators  and  management),  are  now 
springing  up  in  many  parts  of  the  country,  and 
meeting  with  the  success  that  their  enthusiastic 
advocates  have  predicted. 

Now  that  the  evidence  is  growing  that  the  great 
danger  of  acquiring  tuberculosis  is  from  human 
rather  than  animal  patients,  and  that  if  the  disease  is 
ever  destroyed  as  a  pest  of  mankind,  or  even  much 
circumscribed,  it  must  be  chiefly  by  a  systematic 
and  persistent  destruction  of  bacilli  from  human 
expectoration,  the  need  of  such  sustained  care  of 
sputum,  clothing,  and  utensils  of  consumptives  as 
sanatoria  almost  alone  provide  is  l)eing  more  and 
more  appreciated.  But  the  ignorance  on  this  sub- 
ject among  the  people  is  still  very  dense,  and  much 
enlightenment  is  needed  even  among  the  profession. 

The  great  goal  to  work  for  is  an  atmosphere 
charged  as  little  as  possible  with  bacilli  of  tubercu- 
losis. In  no  city  of  any  civilized  country  is  the 
street-air  wholly  free  from  them  now,  and  with 
current  methods  in  the  care  of  tuberculous  patients 
we  cannot  look  for  much  improvement.  Artificial 
destruction  must  reinforce  the  power  of  sunshine 
before  that  desirable  end  is  accomplished,  and  sana- 
toria certainly  succeed,  in  doing  this  1)ctter  than  it  is 
done  anywhere  else.  The  claim  is  not  unfair  that 
19 


290  Tuberculosis 

the  atmosphere  within  the  walls  and  grounds  of  the 
best  of  the  sanatoria  is  more  nearly  germ-free  than 
that  of  the  streets  of  any  city.  An  uninfected  per- 
son is  therefore  safer  within  them  than  at  his  home, 
especially  if  that  is  in  an  urban  community. 

But  the  regulations  and  methods  of  a  sanatorium 
that  is  entitled  to  be  classed  as  the  best  are  some- 
thing startling  in  their  thoroughness.  They  include, 
besides  the  saving  for  destruction  of  every  particle 
of  tangible  sputum,  such  precautions  against  the 
intangible  and  usually  overlooked  but  always  freely 
scattered  minute  particles  of  sputum  as  the  follow- 
ing: Uncarpeted  floors,  unupholstered  furniture, 
and  both  (as  well  as  walls  and  ceilings)  regularly 
cleansed  at  short  intervals  ;  regular  and  frequent  ster- 
ilization by  sunshine  or  heat  of  all  clothing,  beds, 
rugs,  and  every  utensil  used  on  or  about  the  patients. 
They  include  constant  watchfulness  of  the  personal 
habits  of  the  patients,  and  such  searching  precautions 
that  no  l)acilli  discharged  from  any  part  of  the  body 
of  a  patient  can  long  escape  destruction.  And  all 
these  measures  are  carried  out  year  after  year  with- 
out a  break. 

In  what  home  of  a  tuberculous  patient  are  any 
such  thorough  precautions  taken?  And  yet  it  can- 
not be  doubted  that  e\'ery  one  of  them  is  necessary 
f(^r  every  case  if  the  community  is  ever  to  be  pro- 
tected.    The  greatest  danger  is,  of  course,  from  the 


Sanatoria  for  Tuberculosis  291 

poor  and  careless  patients.  All  people  when  greatly 
prostrated  are  liable  to  be  careless  in  their  personal 
habits ;  they  are  almost  certain  to  be.  The  well-to- 
do  and  those  who  have  attentive  friends  can,  in  spite 
of  themselves,  be  kept  in  a  fairly  sanitary  state; 
but  the  neglected  ones  are  a  constant  menace  to 
every  uninfected  person  for  miles  around  them. 
That  menace  is  now  just  coming  to  be  partially 
understood  by  the  public,  and  it  is  beginning  to 
dawn  on  us  that  for  the  common  protection  sanatoria 
at  public  expense  are  needed  for  such  cases.  And 
if  the  science  of  tuberculosis  is  not  wholly  reversed 
by  future  discoveries,  there  will  gradually  develop 
such  a  popular  understanding  of  the  danger  referred 
to  as  will  lead  to  the  creation  of  such  institutions 
all  over  the  country.  The  cost  to  the  public  to 
build  and  support  them  would,  of  course,  be  enor- 
mous, but  the  loss  to  the  community  entailed  by  the 
neglect  of  the  cases  is  now  vastly  more;  it  would 
be  economy  to  take  care  of  them  as  a  ])ublic  burden. 
Great  as  is  the  advantage  to  the  general  jniblic 
in  having  patients  live  in  sanatoria,  the  benefit  to 
the  patients  themselves  is  vastly  more.  They  live 
perforce  hygienical ly,  and  every  day,  and  so  liave  the 
best  chance  of  recovery.  They  take  the  best  care 
of  themselves,  for  that  is  their  occupation ;  and 
they  take  their  peculiar  diet  and  carry  out  the  various 
hygienic   rules   as   a   matter  of  course.     They  eat 


292  Tuberculosis 

properly  and  regularly,  and  so  far  from  violating 
the  details  of  their  regimen,  they  become  advocates 
of  it,  and  watch  themsehes  and  each  other  in  a  loy- 
alty to  it  that  is  both  novel  and  hopeful.  There  are 
no  social  allurements  to  harm ;  the  social  functions 
of  the  institution  are  planned  for  the  sick.  Female 
l)atients  hnve  little  temptation  to  dress  unwhole- 
somely,  and  they  easily  consent  to  wear  short  skirts 
and  loose  clothes  everywhere.  This  last  is  an  almost 
indispensable  condition  to  recovery;  the  conven- 
tional waist-clothing  is  an  abomination  to  the  con- 
sumptive woman.  The  nursing  is  done  by  experts 
who  are  little  moved  to  do  foolish  things  for  the 
patients,  either  at  their  suggestion  or  out  of  blind 
love  and  sympathy  for  them. 

The  danger  of  overdoing  is  minified  by  the  con- 
stant and  wise  watchfulness  that  is  the  habit  of 
the  institution  and  by  the  routine  lives  that  the 
patients  lead  —  which  means  the  highest  degree  of 
wholesome  living;  and  this  is  rarely  attainable  in 
one's  home  unless  at  the  hands  of  a  trained  nurse 
not  of  the  patient's  family.  One  can  live  well  and 
be  well  cared  for  at  a  sanatorium  for  what  such  a 
nurse  often  costs,  or  even  less.  The  constant  sup- 
ply of  fresh  air,  so  hard  to  provide  for  a  patient  at 
his  home,  is  always  secured  at  such  an  institution. 
This  is  the  most  important  remedy,  the  value  of 
which  cannot  be  overrated. 


Sanatoria  for  Tuberculosis  293 

One  of  the  greatest  advantages  of  all  is  the  mental 
tranquillity  that  comes  to  many  patients  through  the 
fact  of  being  in  a  small  community  where  the  chief 
fashions  are  to  be  quiescent  and  to  do  and  endure 
certain  things  that  are  understood  to  be  proper  for 
the  sick.  IMuch  depends  on  the  emotional  basis  on 
which  we  do  things.  At  home  the  basis  is  that  of 
the  well  people,  and  we  seek  to  do  the  things  of  the 
well,  as  in  exercise,  business,  amusements,  and  diver- 
sions, and  eat  always  on  the  basis  of  an  appetite 
which  we  feel  bound  to  cultivate  and  follow. 

In  a  sanatorium  the  basis  is  that  of  the  sick ;  we 
are  glad  to  do  the  things  of  the  sick  in  all  these  par- 
ticulars, and  we  eat  as  a  matter  of  routine,  without 
feeling  compelled  to  pay  homage  to  appetite.  This 
letting  go  of  the  emotional  tension  that  makes  a 
sick  man  try  to  be  a  well  one  and  pretend  that  he 
is,  often  tips  the  balance  in  favor  of  recovery  and 
saves  the  patient  from  a  death  that  otherwise  would 
be  inevitable.  If  every  person  with  pulmonary 
tuberculosis  could  from  the  very  first  give  up  and 
not  pretend  to  himself  or  to  others  that  he  is  well, 
but  settle  down  with  patience  and  attention  to  the 
business  of  getting  well,  the  proportion  of  recoveries 
would  be  greatly  increased. 

The  sanatorium  life  is  conducive  in  a  high  degree 
to  this  good  philosophy.  It  is  attainable  at  home, 
but  less  easily;   there  the  temptation  to  do  all  sorts 


294  Tuberculosis 

of  things  often  begets  an  attempt  to  hide  even  the 
existence  of  tuberculosis  as  though  it  were  a  disgrace 
like  drunkenness  or  opium-taking,  to  be  spoken  of 
only  in  an  undertone,  and  even  forgotten  by  the 
patient.  This  nearly  always  leads  to  the  doing  or 
omission  of  things  that  are  inimical  to  tlie  prospects 
of  recovery.  Those  cases  of  tuberculosis  where 
the  patient  is  perfectly  informed  and  is  himself 
frank  about  it  are  most  of  all  likely  to  recover,  for 
they  pursue,  on  an  average,  a  more  wholesome  course 
of  life  and  treatment,  and  they  are  exposed  to 
decidedly  fewer  risks  of  all  kinds. 

The  proper  placing,  the  location,  of  a  sanatorium 
is  of  great  importance,  although  less  vital  than  the 
management  of  the  patients  within  it.  It  is  essen- 
tial that  it  shall  be  in  the  country,  and  far  away  from 
manufactories  and  all  other  industries  and  things 
that  can  contaminate  the  air  or  render  it  in  the 
slightest  degree  unpleasant  to  the  senses.  Tliere 
ought  to  be  a  free  circulation  of  air,  theref(M'e  an 
elevated  spot  may  be  desirable.  Still,  the  situation 
would  be  unfortunate  if  strong  winds  prevailed  so 
as  to  make  outdoor  life  for  the  patients  difficult. 
High  hills  to  the  east  should  l^e  avoided,  as  they 
make  a  late  sunrise;  an  early  sunset  is  less  objec- 
tionable, but  is  to  be  avoided  if  possible.  Trees 
and  verandas  are  desirable  for  shade  from  the 
intense  sun,  but  never  to  make  it  hard  to  hunt  the 


Sanatoria  for  Tuberculosis  295 

sunshine.  Scenery,  trees,  hills,  rocks,  and  running 
water  are  good  aids  and  make  for  contentment,  but 
are  hardly  to  be  called  essential.  Nearness  to  a 
town  has  its  good  and  its  bad  influences.  Nearness 
means  conveniences,  and  possibility  of  amusements, 
but  it  often  tempts  patients  away  from  the  con- 
tentment with  the  sanatorium  life  that  is  so  necessary 
to  the  best  progress  in  recovery. 

Most  patients  can  never  go  to  a  sanatorium,  but 
must  stay  at  home.  Here  they  recover  if  they  can, 
or  die  if  they  must.  Many  of  them  could  carry 
out  the  true  sanatorium  management  at  home  far 
better  than  they  do ;  most  of  them  never  even  attempt 
it  —  they  find  it  too  radical  and  inconvenient.  For 
these  enforced  stay-at-homes  the  modern  physician 
has  a  large  duty  and  may  do  incalculable  good,  but 
he  can  do  it  only  by  insistence  and  watchfulness  that 
are  sustained  through  the  years,  regardless  of  the 
heedlessness,  impatience,  and  even  censure  on  the 
part  of  the  patients  and  the  public,  and  sustained 
by  a  determination  to  do  a  duty  to  both  tliat  neither 
of  them  can  know  with  any  such  force  as  he  knows 
it. 


NDEX. 


Abscesses,  cold,  97 
Acidity  of  stomach,  209 

sodium    bicarbonate    for, 
209 
Addison's  disease,  37 
Adhesive  straps  to  chest,  221 
A(h-enalin,  274 
Adrenals,  37 
Advice,  lay,  243 
Age,  influence  of,   in  tuberculosis, 

74 
Albuminuria  in  tuberculosis,  97 
Aloes,  253 
Altitudes,  blood-count  in,  240 

efi"ect  of,  239 

in  the  etiology  of  tuberculosis, 

75 
Anatomic  tubercle,  41 

tuberculosis,  37 
Animals,    immunity  of,  to   human 

tuberculosis,  77 
Anodynes,  254 
Antimony,  257 
Antiphthisin,  26 
Apomorphin,    257 
Arid  regions  of  the  United  States, 

233 

Arsenic,  250 

Arytenoids,  tuberculosis  of,  262 
Athletic  exercise,  70 
Auscultation,  109 
Auscultatory  percussion,  107 


Bacilli,  9 

animal  experimentation  with, 

23 
animals  affected,  14 
dangers  from,  163 
death  of,  31 

differing  virulence  of,  78 
distribution  of,  by  sputum,  77 
through  the  body,  means 
of,  66 
effect  of  heat  and  cold  upon, 

15 

extract  of,  284 

in  milk,  21 

in  sputum,  18 

in  tissue,  22 

in  mine,  15 

mode  of  entrance  into   body, 

55 

properties,  12,  13 

staining  methods,  16 

watery  extract  of,  26 
Bad  air,  72 
Baths,  202 

Bladder,  tuberculosis  of,  36 
Blood-count  in  altitudes,  240 
Body,  chart  of,  12I 
Bone  tuberculosis,  41 
Breathing-tubes,  221 
Bronchi,  phlegm  in,  82,  83 

pus  in,  harmlessness  of,  220 
Bronzed  skin  disease,  37 
297 


298 


Index 


Cachexia  in  phthisis,  93 

pathology,  67 
Cacodylate  of  sodium,  250 
Calomel,  254 
Carasso  treatment,  260 
Carpets  and  rugs,  169 
Cascara,  253 
Caseous  degeneration,  30 
Case -taking,  120 
Catarrh,  intestinal,  210 

nasal,  in  tuberculosis,  74 
Catarrhal  pneumonia,  65 
Cattle,  tuberculous,  laws  as  to,  1 70 
Cavities,  114,  127 
Cell,  giant-,  29 

pathology,  53 
Chart  Land  III.,  deaths,  147,  154 
Chart  II.,  deaths  from  phthisis,  149 
Chart  of  body,  121 
Chest,  adhesive  straps  to,  221 

jacket  for  fixation  of,  227 
Chest  protectors,  200 
Child-bearing,  excessive,  73 
Chills,  80,  81 
Climate  in  etiology  of  tuberculosis, 

75 

mild  sea,  242 

nature  of,  231 
Climatic  treatment,  189,  230 
Clothing,   amount   necessary,  201, 
238 

at  night,  256 

disinfection  of,  162 

new  kinds  needed,  I99 
Cloves,  oil  of,  251 
Codein,  254 
Cold  abscesses,  97 

catching,  201 
Cough  at  end  of  expiration,  219 

effect  of  posture  on,  83 


Cough,  harmful,  85 

medicines,  255 

spray  for,  219 

useless,  200 

varieties  of,  82 

voluntary  repression  of,  218 
Creosote  and  guaiacol,  251 
Cure,  when  complete,  i8i 
Curved  fibers  in  sputum,  129 

Death  of  bacilli,  31 

Chart  I.  and  III.  as  showing, 

147,  154 

from   phthisis,    Chart    II.    as 
showing,  149 

percentages  of,  148 

table  of,  146 
Degeneration,  caseoys,  30 
Denison    modification    of    fixation 

plasters,  225 
Diarrhea,  86 

in  tuberculosis,  96 
Diet,  204 
Disinfection,  166 

Drainage  from  colon,   lack  of,  210 
Drugs  in  treatment,  188 

soporific,  271 
Dry  climate,  effect  of,  232 
Dryness  in  etiology  of  tuberculosis, 

75 
Dust  in  lungs,  behavior  of,  57 

Eating,  times  of,  204 
Egg-nog,  207 
Eggs,  curdled,  207 
Enema-habit,  211 
Enemas,  254 

for  intestinal  troubles,  211 
Epididymis,  tuberculosis  of,  35 
Ergot,  273 


Index 


299 


Eucain,  264 
Exercise,  athletic,  70 
Expectorants,  257 
Extractor  tubercle  bacilli,  284 

watery,  of  tubercle  bacilli,   26 
Eye,  glassy,  94 

Fever,  80,  81 

effect  of,  per  se,  89 

exercise  in,  194 

bad  effects  from,  90 

high,  267 

treatment,  193 
Fibers,  curved,  in  sputum,  129 
Fibroid  phthisis,  34 
Fibrosis,  33 

from  lung  motion,  215 

in  different  diseases,  62 

pathology,  61 
Fibrous  form  of  consumption,  44 
Fog,  237 

Food,  articles  of,  205 
Fremitus,  vocal,  105 
Friction-sounds,  116 

Gangrene  of  lungs,  89 
Giant-cell,  29 

jiathology,  53 
Glassy  eye,  94 

Gold  and  sodium  chlorid,  252 
Guaiacol  and  creosote,  251 

external  use,  for  fever,  267 

Health    officers,    notification    of 

cases  to,  167 
Hemorrhage,  treatment,  272 
Horse  serum,  23,  278 
Humidity,  relative,  234 
Hygienic  treatment,  192 
Hypodermoclysis,  276 


Immobilization  of  chest-wall  by 

splint,  227 
Immobilizing    chest    by    adhesive 

straps,  221 
Immunity    of    animals    to    human 

tuberculosis,  77 
Indigestion,  86 
Infection,  mixed,  32 
Insomnia,  194 

treatment,  270 
Intestinal  catarrh,   210 
lodin  trichlorid,  265 
Ipecacuanha,  257 
Iron,  249 

Jacket  for  fixation  of  chest,  227 
Joint-tuberculosis,  36,  41 

Kidneys,  tuberculosis  of,  35 
Koch's  lymph,  24 

Laryngeal  tuberculosis,  35,  39 

treatment,  262 
Lavage,  209 
Laws    as    to    tuberculous    cattle, 

170 
Laxatives,  252 

saline,  253 
Lay  advice,  243 
Life,  outdoor,  195 
Lumbar  puncture,  138 
Lung,  diseased,  management,  214 
rest  for,  214 
dust  in,  behavior  of,  57 
gangrene  of,  89 
pain  in,  81 

tuberculosis,   point   of    begin- 
ning, 56 
Lupus,  41 
Lym]ih,  Koch's,  24 


300 


Index 


Massage,  212 

Meningitis,  tuberculous,  97,  135 

Menstruation  in  tuberculosis,  87 

Miliary  tuberculosis,  42,  65,  99 

Milk  in  biliousness,  208 

Mixed  infection,  32 

Morbidity  of  tuberculosis,  143 

Morpliin  and  opium,  255 

Mortality  from  tuberculosis,  144 

Mouth-percussion,  open,  108 

Mouth-tubes,  184 

Murphy  inflation  treatment,  216 

Muscle  tones,  117 

Muscular  vigor  and  tni)ercuIosis,  70 

Nasai.  catarrh  in  tuberculosis,  74 
Nationality  in  tuberculosis,  75 
Night-sweats,  treatment,  268 
Notification    of    cases     to     health 

officers,  167 
Nuclein,  252 

Oil  of  cloves,  251 

of  pejjpermint,  260 
Opium  and  morphin,  255 
Orthoform.   264 
Out-door  life,  195 
Over-stimulation,  73 

Pain  in  lung,  Si 

rheumatic,  of  throat,  266 
Painlessness  of  consumption,  88 
Peppermint,  oil  of,  260 
Percussion,  106 

auscultatory,  107 

instruments,  107 

open  mouth-,  108 
Peritonitis,  37 

pathology,  58 
Pharj'nx,  tuberculosis  of,  95 


Phlegm  in  bronchi,  82,  83 
Phonendoscope,  iio 
Physical  signs,  lOO 
Pleural  effusion,  140 
Pleurisy,  37 
Pleuritis,  tuberculous,  98,  139 

pathology,  58 
Pneumonia,  catarrhal,  65 
Post-mortem  records,  148 
Posture  as  a  symptom  of  cough,  83 
Pregnancy  in  tuberculosis,  74 
Process,  tuberculous,  27 
Public  speaking  and  singing,  221 
Puncture,  lumbar,  138 
Pus   in   bronchi,    harmlessness  of, 
220 

Qui N IN,  249 

Rales  and  rhonchi,  115 

demonstration  of,  126 
Records,  post-mortem,  148 
Recoveries  from  phthisis,  155 
Red  corpuscles,  increase  of,  in  high 

altitudes,  240 
Resisting  power  to  tuberculosis,  51 
Rest  for  diseased  lung,  214 

how  to  take  it,  197 
Rheumatic  pain  of  throat,  266 
Rhubarb,  253 
Rugs  and  carpets,  169 

Saline  laxatives,  253 

Salol,  251 

Sanatoria  for  poor,  175  _, 
for  tuberculosis,  286 
proper  location  of,  294 
regulations  of,  290 

Scrofula,  42 

Sea  climate,  mild,  242 


Index 


301 


Senega,  257 

Senna,  253 

Serum  from  llie  horse,  23 

Serums,  278 

Short-windedness,  93 

Sight-seeing,  244 

Signs,  voice,  I17 

Singing  and  public  speaking,  221 

Skin  disease,  bronzed,  37 

rubbing  of,  204 
Sleep  in  draft,  198 
Sodium  bicarbonate  for  acidity  of 
stomach,  209 

cacodylate,  250 

phosphate,  253 

sulphate,  233 
Soporific  drugs,  271 
Sources  of  tuberculosis,  76 
Speaking,  public,  and  singing,  221 
Spirometer,  105 
Spray  for  cough,  219 

for  throat,  256,  258,  259,  265 
Sputum,  care  of,  165 

contents  of,  88 

curved  fibers  in,  129 

destruction  of,  164 
Sputum-cups,  165 
Squill,  257 
Staining  bacilli,  methods,  16 

properties  of  bacilli,  12,  13 
Starvation  as  causing  tuberculosis, 

72 
Stethoscopes,  109 
Stimulants,  188 
Stimulation,  over-,  73 
Stomach,  acidity  of,  209 

sodium    bicarbonate    for, 
209 
Strapping  of  chest,  221 
Strychnin,  249 


Sunshine,  amount  desirable,  238 
Suprarenal  extract,  274 
Sweats  of  phthisis,  82,  91 

Tabes  mesenterica,  42 
Temperature,  perceptible,  237 

subnormal,  90 
Test,  tuberculin,  130 
dangers,  132 
rules  for,  131 
Throat,  local  medication  of,  258 

rheumatic  pain  of,  266 

spray  for,  256,  258,  259,  265 
T.  O.,  26 
Tonics,  248 
T.  R.,  26 

Tubercle,  anatomic,  41 
Tuberculin,  24 

for  diagnosis,  25 

hypodermic  use  of,  25 

residuum,   26 

test,  130 

dangers  of,  132 
rules  for,  13I 

therapeutically,  280 

T.  R.,  283 
Tubcrculocidin,  26,  284 
Tuberculosis,  anatomic,  37 

bone,  41 

classification,  43 

complications,  34,  95 

diagnosis,  120 

etiology,  69 

fibroid,  34 

forms  of,  39 

in  utero,  7 1 

miliary,  42,  65,  99 

of  arytenoids,  262 

of  bladder,  36 

of  epididymis,   35 


302 


Index 


Tuberculosis  of  joints,  36,  41 
of  kidneys,  35 
of  larynx,  35,  39 

treatment,  262 
of  pharynx,  95 
patholog)',  51 
prognosis,  143 
prophylaxis,  161 
sources  of,  76. 

spread    of,  from    initial    de- 
posit, 57 
sweats  of,  82,  91 
symptoms,  79 

rate  of  progress,  87 
treatment,  climatic,  189,  230 

general  principles,  177 

medicinal,  238 
Widal  reaction  in.  68,  134 
Tuberculous    cattle,    laws    as    to, 
170 


Tuberculous  meningitis,  135 

pleuritis,   139 

process,  27 
Tubes,  breathing-,  221 

mouth-,  184 

United   States,  arid  regions  of, 
233 

Vesicular  murmur,  126 
Vocal  fremitus,  105 
Voice  signs,  117 
Vomiting,  86 

Watery  extract  of  bacilli,  26 
Weather,  zero,  242 
Widal  reaction  in  tuberculosis,  68, 
134 

X-RAY  in  diagnosis,  142 


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Practice  of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  Dr.  Her- 
mann EiCHHORST,  Professor  of  Special  Pathology  and  Thera- 
peutics and  Director  of  the  Medical  Clinic,  University  of  Zurich. 
Translated  and  edited  by  Augustus  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  Two  oc- 
tavo volumes  of  600  pages  each,  with  over  150  illustrations. 
Prices  per  set :  Cloth,  $6.00  net ;  Sheep  or  Half  Morocco,  $7.50 
net. 

A  NEW  WORK 

BY  ONE  OF  THE  GREATEST  OF  GERMAN  CLINICIANS 

The  Germans  lead  the  world  in  internal  medicine,  and  among  all  Ger- 
man clinicians  no  name  is  more  renowned  than  that  of  the  author  of  this 
work.  Dr.  Eichhorst  stands  to-day  among  the  most  eminent  authorities  in 
the  world,  and  his  Text-Book  of  the  Practice  of  Medicine  is  probably  the 
most  valued  work  of  its  size  on  the  subject.  The  book  is  a  new  one,  but 
on  its  publication  it  sprang  into  immediate  popularity,  and  is  now  one  of 
the  leading  text-books  in  Germany.  It  is  jjractically  a  condensed  edition 
of  the  author's  great  work  on  Si:)ecial  Pathology  and  Therapeutics,  and  it 
forms  not  only  an  ideal  text-book  for  students,  but  a  practical  guide  of  un- 
usual value  to  ])ractising  physicians.  As  the  essential  aim  of  the  physician 
will  always  be  the  cure  of  disease,  the  fullest  and  most  careful  consideration 
has  been  given  t^o  treatment. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Bulletin  of  Johns  Hopkins  Hospital 

"  This  book  is  an  excellent  one  of  its  kind.  Its  completeness,  yet  brevity,  the  clinical 
melliods,  the  excellent  paragraphs  on  trcatnicMit  and  watering-places,  will   make  it  very 

desirable." 

American  Medicine 

"Can  heartily  be  commended  as  not  alone  one  of  the  most  original  and  scholarly  con- 
tribntions  to  recent  medical  literal nre,  but  also  one  of  the  most  practical  and  helpful  text- 
books upon  medicine  in  any  language." 


s.u'.vn/^j^s'  BOOA'S  ox 


THE  BEST  l^IllCllCdH  STANDARD 

Illustrated  Dictionary 

Second  Edition,  Revised 


The  American   Illustrated   Medical  Dictionary.     A  new 

and  complete  dictionary  of  the  terms  used  in  Medicine,  Surgery, 
Dentistry,  Pharmacy,  Chemistry,  and  kindred  branches ;  with 
over  loo  new  and  elaborate  tables  and  many  handsome  illustra- 
tions. By  W.  A.  Newman  Borland,  M.  D.,  Editor  of  "The 
American  Pocket  Medical  Dictionary."  Large  octavo,  nearly 
800  pages,  bound  in  full  flexible  leather.  Price,  ^4.50  net;  with 
thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the 
Lowest  Possible  Cost 

TWO  LARGE  EDITIONS  IN  LESS  THAN  EIGHT  MONTHS 

The  immediate  success  of  tliis  work  is  due  to  the  special  features  that 
distiiiEjuish  it  from  other  hooks  of  its  kind.  It  gives  a  maximum  of  matter 
in  a  minimum  space  and  at  the  lowest  possible  cost.  Though  it  is  practi- 
cally unabridged,  yet  by  the  use  of  thin  bible  pajser  and  flexible  morocco 
binding  it  is  only  l^  inches  thick.  In  this  new  edition  the  book  has  been 
thoroughly  revised,  and  upward  of  one  hundred  imjiortant  new  terms  have 
been  added,  thus  bringing  the  book  absolutely  up  to  date.  The  book  con- 
tains hundreds  of  terms  not  to  be  found  in  any  other  dictionary,  over  lOO 
original  tables,  and  many  handsome  ilhistrations. 


PERSONAL   OPINIONS 


Howard  A.  Kelly.  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University ,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  conve- 
nient size.      No  errors  have  been  found  in  my  use  of  it." 

Roswell  Park,  M.  D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery,  University 
of  Buffalo. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within 
relatively  small  space.  1  find  nothing  to  criticize,  very  much  to  commend,  and  was  inter- 
ested in  finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." 


THE   PRACTICE    OF  MEDIC  I XE 


Saunders' 
American   Year-Book 


The  American   Year=Book  of   Medicine   and  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opin- 
ion in  all  PJranches  of  Medicine  and  Surgery,  drawn  from 
journals,  monographs,  and  text-books  of  the  leading  American 
and  foreign  authors  and  investigators.  Arranged  with  critical 
editorial  comments  by  eminent  American  specialists,  under  the 
editorial  charge  of  George  M.  Goui.d,  M.  D.  In  two  volumes. 
— Vol.  I.,  General  JMeJieuie.  Octavo,  715  pages,  illustrated. 
Vol.  II.,  General  Surgery.  Octavo,  684  ])ages,  illustrated.  Per 
volume:  Cloth,  $3.00  net;  Half  Morocco,  $3.75  net.  Sold  by 
subscription. 

EQUIVALENT  TO  A  POST-GRADUATE  COURSE 

The  contents  of  these  volumes,  critically  selected  from  leading  journals, 
monographs,  and  te.xt-books,  is  much  more  than  a  compilation  of  data.  The 
e.xtracts  are  carefully  edited  and  commented  upon  by  eminent  specialists,  the 
reader  thus  obtaining  not  only  a  yearly  digest  of  scientific  progress  and 
authoritative  o|jinion  in  all  branches  of  medicine  and  surgery,  but  also  the 
invaluable  annotations  and  criticisms  of  the  editors,  all  leaders  in  their  sev- 
eral specialties.  The  work,  moreover,  is  not  lacking  in  its  illustrative  feat- 
ure ;  for,  besides  a  large  number  of  text  cuts,  the  volumes  contain  several 
full-page  plates  of  exceptional  merit. 


OPINIONS  OF  THE  MEDICAL  PRESS 


The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted 
to  experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  com- 
mentaries and  expositions  .  .  .  proceediiit;  from  writers  fully  qualified  lo  perform  these 
tasks." 

Boston  Medical  and  Surgical  Journal 

"  An  imm<;nse  diril  of  work  has  been  put  into  it,  and  the  editor,  seconded  by  a  large 
corps  of  (  (iniiieteni  <  ollaboialors,  has  succeeded  in  satisfactorily  coverinK  the  extended 
field  which  he  has  set  himself  the  task  of  cullivating.  It  is  a  very  desirable  book  for  the 
general  practitioner." 


SAUNDERS'    /iOOA\S    ON 


Gould  and  Pyle's 
Curiosities  of  Medicine 


Anomalies  and  Curiosities  of  Medicine.  By  George  M. 
Gould,  M.  I).,  and  W'ai.ier  L.  Pvle,  M.  ]).  An  encyclopedic 
collection  of  rare  and  extraordinary  cases  and  of  the  most  strik- 
ing instances  of  abnormality  in  all  branches  of  Medicine  and 
Surgery,  derived  from  an  exhaustive  research  of  medical  literature 
from  its  origin  to  the  present  day,  abstracted,  classified,  anno- 
tated, and  indexed.  Handsome  octavo  \olume  of  968  pages, 
295  engravings,  and  12  full-page  plates. 

Popular  Edition  :  Cloth,  $3.00  net ;  Sheep  or  Half  Morocco   J4.OO  net. 


Thi.s  book  is  not  an  illogic  smattering  of  curious  facts,  but  is  .1  complete 
encyclopedia  of  the  whole  .subject.  Several  years  of  exhaustive  research 
have  been  spent  by  the  authors  in  the  great  medical  libraries  of  the  United 
States  and  Europe  in  collecting  the  material  for  the  work.  Medical  litera- 
ture of  all  ages  and  all  hinguages  has  been  carefully  searched,  as  a  glance 
at  the  Bibliographic  Index  will  show  As  a  complete  and  authoritative 
Book  of  Reference  it  will  be  of  value  not  only  to  members  of  the  medical 
profession,  but  to  all  persons  interested  in  general  scientific,  sociologic,  and 
medicolegal  topics ;  in  fact,  the  absence  of  any  complete  work  upon  the  sub- 
ject makes  this  volume  one  of  the  most  important  literary  innovations  of 
the  day. 


OPINIONS  OF  THE  MEDICAL  PRE:SS 


The  Lancet,  London 

■'  Ihe  book  is  a  monument  of  untiring  energy,  keen  discrimination,  and  erudition.  *  *  » 
We  heartily  recommend  it  to  the  profession." 

New  York  Medical  Journal 

"  We  would  >;l.-idly  exchnnge  a  multitude  fif  the  relatively  useless  works  which  but 
encumher  all  branches  <>l  medicine  for  one  so  comprehensive  so  exhaustive,  so  able,  and 
so  remarkable  in  its  field  as  this." 


THE   PRACTICE    OE  MEDIC  EYE 


Anders' 
Practice  of  Medicine 

Fifth  Revised  Edition 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M. 
Anders,  M.  1).,  Ph.  I).,  LL.  D.,  Professor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College, 
Philadelphia.  Handsome  octavo,  1297  pages,  fully  illustrated. 
Cloth,  $5.50  net  ;  Sheep  or  Half  Morocco,  $6.50  net. 

FIVE  LARGE  EDITIONS  IN  FOUR  YEARS 

The  success  of  this  work  as  a  text-book  and  as  a  practical  guide  for 
physicians  has  been  truly  phenomenal.  Five  large  editions  have  been 
called  for  in  less  than  four  years.  The  rapid  exhaustion  of  each  edition 
has  made  it  possible  to  keep  the  book  absolutely  abreast  of  the  times,  so  that 
Anders'  Practice  has  become  justly  celel)rated  a.s  the  most  up  toclate  work 
on  practice.  In  this  edition  extensive  changes  have  been  made  in  connec- 
tion with  the  large  group  of  Infectious  Diseases  The  etiology  and  mode 
of  transmission  of  Malaria  and  of  Yellow  Fever  have  V^een  almost  entirely 
rewritten.  Certain  affections  of  growing  importance,  as  Dij)htheritic  Dysen- 
tery and  Parasitic  IIemo])tysis,  have  been  recast  and  more  fully  discussed. 
The  new  articles  include  Fatty  Infiltration  of  the  Heart,  Streptococcus  Pneu- 
monia, and  Acute  Diffuse  Interstitial  Nephritis. 


PERSONAL   OPINIONS 


James  C.  Wilson,  M.  D., 

Pr/)/essiu-  I'/  the  Practice  of  Medicine  and  of  Clinical  Medicine.  Jefferson  Medical 
Collide,  I'/tiladel/>hia. 

"  It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up-to-date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 

A.  C.  Cowperthwait,  M.  D., 

President  if  ilte  Illinois  Homeopathic  Medical  Association. 

"  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by- 
far  the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully 
up-to-date  in  everylliiiig.  I  consider  it  a  great  creilit  tn  both  tliu  author  and  the  pub- 
lishers," 


SAUA'DERS-  BOOK'S    ON 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

i;ni>ek  the  KDiroRiAi,  sui'i:r\  isiuN  ok 

ALFRED   STENGEL,  M.D. 

Professor  of  Clinical  Medicine  in  the  University  of  I'cnnsylvania;  Visiting 
rhysician  to  the  Pennsylvania  Hospital. 


BEST  IN 
EXISTENCE 


FOR  THE 
PRACTITIONER 


It  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
Medicine;  and  of  all  the  German  works  on  this  subject,  Nolhnagel's  "  Speci- 
elle  Pathologic  und  Tiieraijie"  is  conceded  by  scholars  to  be  without  question 
the  best  Practice  of  Medicine  in  existence.  So 
necessary  is  this  l)ook  in  the  study  of  Internal  Medi- 
cine that  it  comes  largely  to  this  country  in  the  orig- 
inal German  In  view  of  these  facts,  Messrs.  W.  B. 
.Saundi'rs  &  Company  have  arranged  with  the  pub- 
lishers of  the  (ierman  edition  to  issue  at  once  an 
authorized  .Vniericaii  edition  of  this  great  Practice  of  Medicine. 

For  the  present  a  set  of  ten  volumes,  selected  witli  especial  thought  of  the 
needs  of  the  practising  physician,  will  be  published.  These  volumes  will  con- 
tain the  real  essence  of  the  entire  work,  and  the 
jiurchaser  will  therefore  obtain,  at  less  than  lialf  the 
cost,  the  cream  of  the  original.  1  ,nter  the  special  and 
more  strictly  scientific  vohinies  will  be  offered  from 
time  to  time. 

The  work  will  be  translated  by  men  possessing 
thorougii  knowledge  of  both  linglish  and  German,  and  each  V(jhime  will  be 
edited  by  a  prominent  specialist.  It  will  thus  be  brought  thoroughly  up  to  date, 
and  tiie  .American  edition  will  be  more  than  a  mere  translation  ;  for,  in  addition 
to  the  matter  contained  in  the  original,  it  will  rcpre- 
-^ent  the  very  latest  views  of  the  leading  American  and 
h'nglish  specialists  in  the  various  di  partnients  of  In- 
ternal Medicine.  Moreover,  as  each  volume  will  be 
revised  to  the  date  of  its  pnbMcation  by  the  eminent 
editor,  the  objection  that  has  heretofore  existed  to 
treatises  published  in  a  number  of  volumes  will  be  obviated,  since  the  subscriber 
will  receive  the  comjileted  work  while  the  earlier  volumes  are  still  fresh.  The 
.American  publication  of  the  entire  work  is  under  the  ediloi  ial  supervision  of  Dr. 
Ai.i'Ki'.l)  Stkncki,,  who  has  selected  the  subjects  for  the  American  P^dition,  and 
has  chosen  the  editors  of  the  different  volumes. 

The  usual  method  of  publishers  when  issuing  a 
publication  of  this  kind  has  been  to  compel  physi- 
cians to  take  the  entire  work.  This  seems  to  us  in 
manv  cases  to  be  undesirable.  Therefore,  in  pur- 
chasing this  Practice  jihysicinns  will  be  given  the 
opportunity  of  subscribing  for  it  in  entirety  ;  but  any  single  vohmie  or  any  number 
of  volumes,  each  complete  in  itself,  may  be  obtained  by  those  who  do  not  desire 
the  complete  series.  This  latter  method  offers  to  the  purchaser  many  advantages 
which  will  be  appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire 
work  at  one  lime. 

SEE    NEXT  TWO   PAGES   FOR   LIST 


PROMINENT 
SPECIALISTS 


VOLUMES  SOLD 
SEPARATELY 


THE   PRACTICE    OF  MEDICINE 


AMERICAN  EDITION 


NothnageTs  Practice 

VOLUMES    NOW    READY 


Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Cukschm ann,  of  Leipsic.  The  entire  volume  edited,  with 
additions,  by  Wm.  Osi.ek,  M.  D.  ,  F.  R.  C.  P.,  Professor  of  the  Principles 
and  Practice  of  Medicine,  Johns  Hopkins  University,  Bait.  Octavo,  646 
pages,  illustrated.     Cloth,  jg5.oo  net ;    Half  Morocco,  $6.00  net. 

"  The  monograph  on  typhoid  fever  is  the  best  exponent  of  the  knowledge  that  we 
have  in  regard  to  this  disease  that  is  to  be  had  in  any  language. "^yy«r««/  of  the 
A»ie>'can  Mt'dical  Association. 

Smallpox  (including  Vaccination),  Varicella,  Cholera 
Asiatica,  Cholera  Nostras,  Erysipelas,  Erysipe- 
loid, Pertussis,  and  Hay  Fever 

By  I)K.  H.  ImmI'.kmann,  of  Basle;  I)K.  Tn.  vox  Jukgknskn,  of 
Tubingen;  Dk.  C.  LiEBKKMK.is  IKR,  of  Tiihingen  ;  JJR.  H.  Lknhar  iz, 
of  Hamburg;  and  Dk.  G.  Siickkr,  of  (jiessen.  The  entire  volume 
edited,  with  additions,  by  .Sir  J.  W.  ModRK,  M.  D.,  F.  R.  C.  P.  I., 
Professor  (if  Practice,  Royal  College  of  Surgeons,  Ireland.  Octavo, 
682  pages,  illustrated.      Cloth,  $5.00  net ;   Half  Morocco,  $6.00  net. 

"  Dr.  Immermann's  vindication  of  vaccination  in  the  prophylaxis  of  smallpox  .  .  . 
is  probably  the  most  complete  and  unassailable  indictment  of  the  propaganda  of  anti- 
vaccination  fanatics  which  has  ever  been  published." — I'he  Londoi  Lancet. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  Wii, 1.1AM  P.  NiikriiKfi',  M.  1).,  of  Nt-w  York,  ami  I)k.  Th.  Vhn 
JURGENSF.N,  of  I  ubingen.  The  entire  volume  edited,  with  additions, 
by  Wii.l.iAM  P.  NdRiHRiU',  M.  D.,  Professor  of  Pediatrics,  University 
and  Bellevue  Hospital  Medical  College,  New  ^'()rk.  Octavo,  672 
pages,  illustrated,  including  24  full-page  plates,  3  in  cnlors.  Cloth, 
^5.00  net  ;    Half  Morocco,  $6.00  net. 

"The  authors  are  to  be  congratulated.  .  .  .  The  articles  are  exhaustive  treatises, 
with  ininierous  additions  by  the  .American  editor." — Journal  0/  the  Atiierican  Medi- 
cal .Is.sOi  iatiiin. 

Diseases  of  Bronchi  and  Pleura ;  Inflammations  of 
the  Lungs 

By  Dk.  F.  a.  lIoiKMANN,  of  I.eipsic;  Dk  O.  RnsKMiAcn,  of  Ber- 
lin; and  Dk.  V.  A(n''Ki:ciiT,  of  Magdeburg.  The  entire  volume  ediied, 
with  additions,  l)y  JollN  H.  Musskk,  M.  i)..  Professor  of  Clinical  Medi- 
cine, University  of  Pennsylvania.  ( )ctavo,  1029  pages,  illustrated,  in- 
cluding 7  full-page  colored  lithographic  plates.  Cloth,  5500  net ; 
Half  Morocco,  #6.00  net. 

Much  new  matter  has  been  incorporated  into  thif  section  on  pneumoniri,  and  refer- 
ences to  the  work  of  Morse  on  the  leukocytes  in  pleurisy,  to  that  <ir  Williams  and 
others  on  X-ray  diagnosis,  and  in  tlu-  i.itten  phenomenon,  are  included. 


SAiWDERS'    BOOK'S   OX 


AMERICAN  EDITION 

NothnageTs  Practice 

VOLUMES  NOW  READY  AND  IN  PRESS 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

Hv  I»R.  I^.  0^i;r,  of  \'iciin;T  ;  I)r.  K.  Nkussi  r,  of  X'ienna,  and  Drs. 
II.  (^LINCKF.  and  G.  I  lorric-SKYLKR,  of  Kiel.  The  entire  volume  edited, 
with  additions,  by  RkginaI-D  II.  Frrz,  A  M..  M.D.,  Hersey  Professor  of 
the  Theory  and  Practice  of  Physic,  Harvard  University;  and  Frederick 
A.  P.ACKARD.  M.D.,  Late  Physician  to  the  Pennsylvania  and  to  the 
Children's  Hospitals.  Octavo  of  918  pages,  illustrated.  Cloth,  $5.00 
net;   Half  Morocco,  $6.00  net. 

It  has  been  the  aim  of  the  authors  and  editors  of  this  work  to  describe  the  present 
condition  of  our  knowledge  on  the  subjects,  to  point  out  where  it  is  deficient,  and  to 
stimulate  to  new  work.     The  work  will  be  found  practical  in  everj'  particular. 

Diseases  of  the  Stomach 

Uy  Dr.  F.  Rikjkl,  of  (licssen.  Edited,  with  additions,  by  CHARLES 
G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buffalo. 
Handsome  octavo  of  S35  pages,  with  29  te.\t-cuts  and  6  full-page  plates. 
Cloth,  $5.00  net ;   Half  Morocco,  $6.00  net. 

This  work  is  a  complete  exposition  of  the  diseases  of  the  stomach.  Full  considera- 
tion is  given  to  the  hydrochloric  acid  ([uestion.  the  latest  views  being  incorporated  by  the 
editor.     Particular  attention  has  been  given  to  ilistiiibaiues  of  motility  and  secretion. 

Diseases  of  the  Intestines  and  Peritoneum 

I5v  Dr.  Hi-.RMann  No  ihna(;f.i.,  of  \'ienna.  The  entire  volume 
edited,  with  additions,  by  IIumi'HRFY  D.  Roi.i.kston,  M.  D.,  F.  R.  C.  P., 
Physician  to  and  Lecturer  on  Pathology  at  St.  George's  Hospital,  Lon- 
don.     Handsome  octavo  of  f-oo  pages,  finely  illustmted. 

Influenza,  Dengue,  Malarial  Diseases 

By  Dr.  O.  Leiciitknstf.rx,  of  Cologne,  and  Dr.  J.  Mannaberg, 
of  Vienna.  The  entire  volume  edited,  with  additions,  by  Ronai,!) 
Ross,  F.  R.  C.  S.,  Fnc,  D.  P.  H.,  F.  R.  S.,  Major,  Indian  Medical 
Service,  retired  ;  Walter  Myers  Lecturer,  I.iver])Of)l  .School  of  Tropical 
Medicine,  Liverpool.  Handsome  octavo  of  700  pages,  with  7  full-page 
lithographic  plates  in  colors. 

Anemia,  Leukemia,   Pseudoleukemia,  Hemogiobine- 
mia,  and  Chlorosis 

By  Dr.  P.  Ehriicu,  of  Frankfort-on-the-Main ;  Dr.  A.  Lazarus, 
of  Charlottenburg  ;  Dr.  Felix  Pinki's,  of  Berlin;  and  Dr.  K.  von 
NoORDEN.  of  Frankfort-on-the-Main.  The  entire  volume  edited,  with 
additions,  by  Alfred  Stencel,  M.  I).,  Professor  of  Clinical  Medicine, 
University  of  Pennsylvania.  Handsome  octavo  of  750  pages,  with  5 
full-page  lithographs  in  colors. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

r,\-  \\\i.  (1.  ('mi:ni  r.  of  I'xtHii.  Handsome  octavo  of  7C0  ]jages. 
The  fditor  of  this  vohnne  will  be  aimoiiticcd  later. 

EACH  VOLUME  COMPLETE  IN  ITSELF,  AND  SOLD  SEPARATELY 


MATERIA    MEDIC  A   AND    THERAPEUTICS 

Stevens' 
Modern  Therapeutics 


A  Text=Book  of  Modern  Therapeutics.  By  A.  A.  Stevens, 
A.  M.,  M.  1).,  Lecturer  on  Physical  Diagnosis  in  the  Uni- 
versity of  Pennsylvania.  Handsome  octavo  of  about  600  pages. 
Cloth,  $0.00  net. 

THIRD  EDITION,  ENTIRELY  REWRITTEN  AND  GREATLY 
ENLARGED 

Since  the  appearance  of  the  last  edition  of  this  book  such  rapid  advances 
have  been  made  in  Materia  Medica,  Therapeutics,  and  the  allied  sciences 
that  the  author  felt  it  imperative  to  rev^'rite  the  work  entirely.  All  the  newer 
remedies  that  have  won  approval  by  recognized  authorities  have  been  incor- 
porated, bringing  the  book  absolutely  down  to  date.  It  is  based  on  the 
latest  edition  of  the  Phannacopa-ia,  and  includes  the  following  section-^ : 
Physiologic  Action  of  Drugs ;  Drugs  ;  Remedial  Measures  other  than 
Drugs;  Applied  Therapeutics;  Incompatibility  in  I'rescri])lions ;  Table  of 
Doses;  Index  of  I  )rugs  ;  and  Index  of  Diseases;  the  treatment  being  eluci- 
dated by  more  than  two  hundred  formula. 


OPINIONS  OF  THE  MEDICAL  PRESS 


New  York  Medical  Journal 

"  I'lic  work  wliicli  Ur.  Stevens  has  written  is  far  superior  to  most  of  its  class  ;  in  fact, 
it  is  very  goricl.   .   .  .  The  boolc  is  reliable  and  accurate." 

University  Medical  Magazine 

"  'I'lic  aiitliiir  h;is  faithfully  jiresented  modern  llierapeutics  in  a  comprehensive  work 
.  .  .  and  it  will  be  found  a  relialile  guide  and  suffnicnlly  i:omijrehensive  for  the  i)liysiiian 
in  practice." 

Bristol  Medico-Chirurgical  Journal,  Bristol 

"  'I'liis  adiliiion  to  the  nnmi  icms  wurks  on  I'hirapentics  is  distinctly  a  good  one.  .  .  . 
It  is  to  be  recommended  as  beinj;  syslnnalic,  clear,  concise,  very  fairly  up  to  date,  and 
carefidly  indexed." 


S.irA7)/:A\S'   BOOA'S  o.v 


Sollmann's 
Text-Book  of  Pharmacology 

Including*  Therapeutics,  Materia  Medica,  Pharmacy, 
Prescription-writing,  Toxicology,  etc. 


A  Text=Book  of  Pharmacology  :  including  Therapeutics, 

MaTKRIA      MkJUCA,      I'IIAKMACN,      PRESCRIPTION-WRiriNO,     Toxi- 

coLO(;v,  etc.  By  Torai,!)  Soi.lmann,  M.  D.,  Assistant  Pro- 
fessor of  Phariiiacoloi^y  and  Materia  Medica,  Medical  Depart- 
ment of  Western  Reserve  University,  Cleveland,  Ohio.  Hand- 
some octa\o  \olume  of  CS94  pages,  fully  illustrated.  Cloth,  $3.75 
net. 

A  NEW  WORK— JUST  ISSUED 

This  work  aims  to  furnisli.  in  a  manner  suited  for  reference  and  study,  a 
scientific  discussion  and  definite  conception  of  the  action  of  drugs,  as  well 
as  their  derivation,  composition,  strength,  and  dose.  The  authf)r  bases  the 
study  of  therapeutics  on  a  .systematic  knowledge  of  the  nature  and  properties 
of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between  ])harma- 
cology  and  practical  medicine.  Practitioners  and  students  will  find  the  \\()rk 
an  admirable  guide  in  that  most  important  part  of  their  e(juipment,  namely, 
how  to  use  drugs  accurately  and  efficaciously. 


PERSONAL  AND  PRESS  OPINIONS 


J.  F.  Fotheringham,  M.  D.. 

Professor  of  Tlu-rapeutics  and  T/iroi y  ami  rriictite  of  Pri-scribhig,  Trinity  Mciiical 

College,  Toronto. 

"  The  work  certainly  occupies  groiiiul  mil  <  overid  in  so  concise  useful,  and  scientific 
a  manner  by  any  other  text  1  have  read  on  the  subjects  embraced." — October  30,  iqoi. 

Medical  News,  New  York 

'•  It  has  r:irclv  bc.n  onr  fortune  to  review  so  clear,  concise,  aiul  well  arranered  a  work. 
.  .  .  The  pharmacist  will  find  welcome  information  which  other  books  en  the  same  subject 
usually  neglect.     We  consider  the  book  one  of  the  best." 


MATERIA    MF.DICA    AXD    THERAPEUTICS  13 

Butler's    Materia    Medica, 

Therapeutics,  and   Pharmacology 


A  Text=Book  of  Materia  Medica,  Therapeutics,  and 
Pharmacology.  J5y  George  F.  Butler,  Ph.  G.,  M.  I).,  Pro- 
fessor of  Materia  Medica  and  of  Clinical  Medicine,  College  of 
Physicians  and  Surgeons,  Chicago.  Octavo,  896  images,  illus- 
trated.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

FOURTH  EDITION,  REVISED  AND  ENLARGED 

In  this  new  edition  tlie  work  lias  been  thoroughly  revised  and  remod- 
eled, brini^ing  it  absolutely  down  to  date.  The  pharmacology  and  thera- 
peutics of  each  drug  have  been  thoroughly  revised,  incorporating  all  the 
recent  advances  made  in  pharmacodynamics.  In  view  of  a  larger  experience, 
resulting  in  more  definite  conclusions,  numerous  changes  have  been  made  in 
the  expressions  of  opinion  regarding  the  utility  of  certain  drugs,  notably  the 
newer  synthetics.  The  chapters  on  Organo-therapy,  Serum  therapy,  and 
cognate  subjects  have  been  enlarged  and  carefully  revised,  so  that  they  now 
portray  the  present  knowledge,  on  these  subjects.  But  perhaps  the  most 
important  addition  is  the  chapter  devoted  to  the  newer  theories  of  electro- 
lytic dissociation  and  its  relation  to  the  to])ic  of  pharmacotherapy,  and  the 
relevant  discussion  added  of  the  simpler  relations  of  chemical  structure  of 
drug-action.  A  .section  on  "The  Relation  of  I'liysical  Chemistry  to  I'har- 
macology  and  Therapeutics "'  has  also  been  added. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Journal  of  the  American  Medical  Association 

"  That  the  wnik  is  (|uiiu  up  to  ilalr  is  sciii  by  tliu  section  on  orpaiio-tlierapy  and 
senim-therai)y .  .  .  .  Takt-Mi  as  a  whole,  the  book  may  he  considered  as  one  ol'  the  most 
satisfactory  single-volume  works  on  materia  medica  on  the  market." 

Medical  Record,  New  York 

"  Ni.thini;  has  licin  omitted  liy  the  author  which,  in  liis  jndjjnu-nt,  would  add  to  llie 
cotnpletencss  of  tile  text,  and  the  sludent  or  j;<-'!'t'ral  reader  is  ;fiven  the  hcnefit  of  latest 
advices  bearing  upon  the  value  of  drugs  and  remedies  considered." 


14  SAUXDEJiS'    BOOK'S    OX 

Thornton's  Dose-Book 

Dose=Book  and  Manual  of   Prescription=Writing.     \\y 

E.  Q.  Thornton',  M.  1).,  Demonstrator  of  Therapeutics,  Jef- 
ferson Medical  College,  Phila.  Post-octavo,  362  pages,  illus- 
trated.     Flexible  Leather,  52. 00  net. 

SECOND  EDITION.  REVISED  AND  ENLARGED 

In  this  new  edition  additions  have  been  made  to  the  chapters  on  "  Pre- 
scription-Writing" and  '•Incompatibilities,"  and  references  have  been  in- 
troduced in  the  text  to  the  newer  curative  sera,  organic  extracts,  synthetic 
compounds,  and  vegetable  drugs.  To  the  Appendix,  chapters  upon  Syno- 
nyms and  Poisons  and  their  antidotes  have  been  added. 

C.  H.  Miller.  M.  D.. 

Frofcssor  0/  PJiarinacology,  North-Mfstern  Unh'crsity  Medical  School ,  Chicago. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the 
correct  terminology  as  used  in  prescription-writinff,  and  it  will  afford  me  mucli  pleasure  to 
recommend  the  book  to  my  classes,  who  often  fail  to  find  this  information  in  ilieir  other 
text-books." 

American  Text-Book  of 
Applied  Therapeutics 

American  Text=Book  of  Applied  Therapeutics.  Edited 
by  James  C.  Wilson,  INl.  D.,  Professor  of  Practice  of  Medicine 
and  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadel- 
phia. Handsome  imperial  octavo  volume  of  1326  pages.  Illus- 
trated.    Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net. 

FOR  STUDENT  AND  PRACTITIONER 

Written  for  both  the  student  and  jiractitioncr,  tlie  aim  of  this  work  is  to 
facilitate  the  application  of  knowledge  to  the  prevention,  cure,  anil  allevia- 
tion of  disease.  The  endeavor  throughout  lias  been  to  conform  to  the  title 
of  the  book — "Applied  Thera]5eulics  " — to  indicate  the  cotirse  of  treatment 
to  be  pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  liave 
been  used  at  one  time  or  another. 

Buffalo  Medical  Journal 

'■  It  is  one  (if  the  most  complete  books  of  ri.-ference  that  has  been  presented  to  the  pro- 
fession on  medicine  in  a  long  perioil  of  time ;  and  never  before  have  we  had  one  that  under- 
took to  cover  the  field  in  this  manner." 


MATERIA    MEDIC  A    AND    1  HERA  PEL  TICS  15 

The  American  Pocket  Medical  Dictionary. 

Third  Edition,  Revised 

The  American  Pockkt  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of 
the  University  of  Pennsylvania.  Containing  the  pronunciation  and  defi- 
nition of  the  principal  words  used  in  medicine  and  kindred  sciences, 
with  64  extensive  taiiles.  Flexible  leather,  with  gold  edges,  $1.00  net; 
with  thumb  index,  ^1.25  net. 

Vierordt's  Medical  Diagnosis.     Fourth  Edition.  Revised 

Medical  Diagnosis.  By  Dr.  Oswald  Viekordt,  Professor  of 
Medicine,  University  of  Heidelberg.  Translated  from  the  fifth  enlarged 
German  edition  by  Francis  H.  Stuart,  A.M.,  M.D.  Octavo,  603 
pages,  104  wood  cuts.  Cloth,  $4.00  net ;  Sheep  or  Half  Morocco,  ;^5.00 
net. 

Cohen   and   Eshner's    Diagnosis.     Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Coiien,  M.  D.,  Lecturer 
on  Clinical  Medicine,  Jefferson  Medical  College,  Phila. ;  and  A.  A. 
EsHNER,  M.  D.,  Professor  of  Clinical  Medicine,  Philadeljihia  Polyclinic. 
Post-octavo,  382  pages;  55  illustratiuns.  Clotli,  $1.00  net.  In  Saunders' 
Question-  Compcnd  Scries. 

Morris'  Materia  Medica  and  Therapeutics. 

Fifth  Revised  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescrip- 
tion-Writing. By  Henry  Morris,  M.  D.,  late  Demonstrator  of 
Therapeutics,  Jefferson  Medical  College,  Phila.  Post-octavo,  250  pages. 
Cloth,  $1.00  net.      In  Saunders'    Question- Coiiipend  Series. 

Sayre's  Practice  of  Pharmacy.    Second  Edition,  Revised 

ESSENI  !ALS      OF      THE       PRACTICE       OK      I'llARMACY.       By     LUCIUS     E. 

Sayre,  M.  D.,  Professor  of  Pharmacy,  University  of  Kansas.    Post-octavo, 

200  [)ages.     Cloth,  $1.00  net.      In  Saunders'  Question  Conipend  Series. 

Brockway's    Medical    Physics.      Second  Edition,  Revised 

Essentials  of  Medical  Physics.  By  Fred.  J.  15rockway,  M.  D., 
late  Assistant  Demonstrator  of  Anatomy,  College  of  Physicians  and  Sur- 
geons, N.  Y.  Post-octavo,  330  pages;  155  fine  illustrations.  Cloth, 
$1.00  net.     In  Saunders''    Question-Compend  Series. 

Stoney's  Materia  Medica  for  Nurses 

Materia  Medica  fhk  Xi'iois.  By  l.Mii.v  .\.  M.  Stoney,  Super- 
intendent of  the  Training  School  for  Nurses  at  the  Carney  Hospital, 
South   Boston,  Mass.      Handsome  octavo  volume  of  306  pages.     Cloth, 

,'>I.50  net. 

Grafstrom's  Mechano-therapy 

A  TEXT-Bof)K  of  Mechano-'I  herapy  (Massage  and  Medical  Gym- 
nastics). By  Axel  V.  Grafsirom,  B.  Sc,  M.  D.,  late  House  Physician, 
City  Hos]iital,  lilackweU's  Island,  .\.  \ .  I2mo,  139  pages,  illustrated. 
Cloth,  $1.00  net. 


i6  SAUXDERS'    BOOK'S    OX  PRACTICE,  Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

AlI.ASANl)  El'lToMr.  i  iK  ImEKNAI.  M  1  lUCl  NE  A.ND  Cl.IMCAl,  DIAG- 
NOSIS. By  Dr.  Chr.  Jakdh,  of  Erlangen.  Edited,  with  additions,  by 
A.  A.  EsiiNKR,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia 
Polyclinic.  W  ith  182  colored  Ht^ures  on  68  plates,  64  text-illustrations, 
259  pages  of  te.xt.      Cloth,  $3.00  net.      In  Saunders'  Hand-Alias  Series. 

Lockwood-s  Practice  of  Medicine.  Rewtir'n^el^ed 

A  Manual  ok  ihk  Pkactick  of  MEDiciM..  l!y  (lico.  Rok  I.orK- 
Woou,  M.  D.,  Attending  Physician  to  the  Bellevue  Hospital,  New  York 
City.  Octavo,  S47  pages,  with  79  illustrations  in  the  text  and  22  full- 
page  plates.      Cloth,  $4.00  net. 

Saling^er  and  Kalteyer's  Modern  Medicine 

Moni.KN  Mkhii'im:.  P>y  Ji'IK's  L.  Sai.ingi  i:,  M.D.,  late  r)emon- 
strator  of  Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J. 
Kai.TEYER,M.  D.,  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.      Handsome  octavo,  801  pages,  illustrateil.      Cloth,  $4.00  net. 

Keating's  Life  Insurance 

How  TO  ExAMiNK  i-oR  l.iiE  INSURANCE.  By  the  Lite  John  M. 
Keating,  M.  D.,  Ex-President  of  the  Association  of  Life  Insurance 
Medical  Directors.  Royal  octavo,  211  pages.  With  numerous  illustra- 
tions.     Cloth,  $2.00  net. 

Corwin's    Physical    Diagnosis.      Third  Edition,  Revised 

|■',-^^ENTIAI.S    Ol'     l'HV-,IC\L     MlAGNo.MS    (_)l'     'l  M  K    'i'HoKA.N.        P)y    .\.    M. 

C"oK\Vl.N,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago.  220  pages,  illustrated.  Cloth,  flexible 
covers,  $1.25  net. 

American  Text-Book  of  Theory  and  Practice 

.VmI  KKAN    TlXl'-lJooK  o:-    IHi;'rm()KV   AM)   pKAilK  I    ol-   MeUICINE. 

Etlited  by  the  late  Will. iam  Pepper,  M.  D.,  I.E.  D.,  Professor  of  the 
Tiicory  and  Practice  of  Medicine  and  of  Clinical  Medicine,  University 
of  Peiina.  Two  hand.sonie  imperial  octavos  of  about  1000  pages  eaih. 
Illustrated.  Per  volume  :  Cloth,  $5-^0  ^^^  >  Sheep  or  Half  Morocco, 
$0.00  net. 

Stevens*  Practice  of  Medicine.     Fifth  Edition,  Revised 

A  Manual  of  thk.  Pk  a(  i  kk  oi-  Mi  dicinf.  I!y  .\.  A.  Stfvens, 
A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis,  University  of  Pennsyl- 
vania. Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  P^lexible 
leather,  $2.00  net. 


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